Fixation Of Humerus Fractures Research Articles

United States opioid prescribing trends after shoulder surgery and their correlation with opioid misuse

BACKGROUNDOrthopedic surgery has been highlighted as a contributor to the opioid epidemic. There is a paucity of literature focused specifically on opioid prescribing trends following shoulder surgery. Our aims were to describe national and regional trends in opioid prescribing following total shoulder arthroplasty (TSA), proximal humerus fracture fixation, and rotator cuff repair (RCR), and to correlate opioid prescribing trends after shoulder surgery with regional heroin use and new opioid misuse diagnoses. METHODSThis is a retrospective study of 218,577 patients from a commercial insurance dataset who had undergone orthopedic shoulder procedures from 2014-2020. Opioid prescription data within 90-day postop were converted to morphine milligram equivalents (MME). Multivariate modelling was used to evaluate independent associations between MME’s prescribed and subsequent new postoperative diagnosis of opioid dependence. Additionally, longitudinal mixed effects modeling was employed to understand aggregated prescriber habits by state over time and the subsequent effects on estimates of state heroin use and drug overdose deaths. RESULTSFrom 2014 to 2020, the mean number of MMEs prescribed nationally decreased by over 50% for TSA, proximal humerus fracture fixation, and RCR. Over the study period, most states demonstrated an overall downtrend of 90-day opioid prescribing for these procedures.Individuals with a new opioid misuse diagnosis following shoulder surgery were found to be younger (SMD=0.27, p<0.001), have increased comorbidities (SMD=0.38, p<0.001), and increased MME’s prescribed (SMD=0.94, p<0.001). Increased comorbidity score (OR=3.28, p<0.001) and increased 90-day MME’s prescribed (OR=1.05, p<0.001) were all found to increase the odds ratio of a postoperative opioid misuse diagnosis in patient’s undergoing shoulder surgery, while increased age (OR=0.97, p<0.001) and patient’s undergoing RCR (OR=0.79, p=0.001) were found to have a decreased odds ratio of developing a new opioid misuse diagnosis.The predictors of regional heroin use included the within-state 90-day MMEs prescribed (p=0.002). The predictors of drug overdose death included year (p<0.001), but did not include type of surgery or 90-day MMEs. CONCLUSIONOrthopedic surgeons successfully reduced the number of opioids prescribed nationally after shoulder surgeries by over 50% during our study period with similar trends seen at the state level. Our data indicate a relationship between increased opioid prescribing after shoulder surgery and heroin use. This study highlights that while progress has been made, there is evidence that opioid prescribing following shoulder surgery is associated with the more widespread opioid epidemic, and that more research is needed to further lower postoperative opioid misuse in the future.

Intra-operative subperiosteal elevation of the ulnar nerve is a safe and effective way to minimize post-operative ulnar neuritis in distal humerus fractures.

To describe subperiosteal elevation of the ulnar nerve and compare to anterior transposition and in situ decompression techniques. Design: Retrospective comparative study. Urban Level 1 trauma center. Distal humerus fractures (OTA/AO 13) treated with open reduction internal fixation between 2014-2022. Rate of pre- and post-operative neuritis grouped by management of the ulnar nerve. During subperiosteal elevation, the ulnar nerve was identified and raised off the ulna subperiosteally and mobilized submuscularly anterior to the medial epicondyle to protect the nerve. The nerve was released only laterally off the triceps and the medial soft tissue attachment is maintained. The main outcomes measurements was rate of neuritis documented within physical exam. Within the 125 patients, 35 underwent subperiosteal elevation (mean age of 56 ± 21 years, 57% female), 63 in situ decompression (mean age of 60 ± 18 years, 46% female), and 27 anterior transposition (mean age of 55 ± 20 years, 59% female). Pre-operative ulnar neuritis was present in 34%, 21%, and 33% of patients treated with subperiosteal elevation, in situ decompression, and anterior transposition, respectively (p=0.26). At post-operative evaluation symptom resolution occurred in 100%, 69%, and 33% of patients treated with subperiosteal elevation, in situ decompression, and anterior transposition, respectively (p=0.003). New cases of post-operative ulnar neuritis occurred in 6%, 8%, and 26% of patients treated with subperiosteal elevation, in situ decompression, and anterior transposition, respectively (p=0.054). Subperiosteal elevation outperformed anterior transposition regarding post-operative ulnar neuritis (p=0.019) and symptom resolution (p=0.002) and performed similarly to in situ decompression (p>0.05). On multiple regression analysis, anterior transposition was an independent risk factor for post-operative neuritis (OR=5.2, p=0.023). Subperiosteal elevation is an effective way to minimize post-operative neuritis and similar to an in-situ decompression during distal humerus fracture fixation. Based on the results of this cohort, authors recommended that anterior transposition of the ulnar nerve be used with caution due to association with post-operative ulnar neuritis. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for dysfunctional elbow stiffness following operative fixation of distal humerus fractures

BackgroundElbow stiffness is one of the most common complications after operative fixation of distal humerus fractures; however, there is relatively limited literature assessing which factors are associated with this problem. The purpose of this study is to identify risk factors associated with dysfunctional elbow stiffness in distal humerus fractures after operative fixation. MethodsA retrospective review of all distal humerus fractures that underwent operative fixation (AO/OTA 13A-C) at a single level 1 trauma center from November 2014 to October 2021. A minimum six-month follow-up was required for inclusion or the outcome of interest. Dysfunctional elbow stiffness was defined as a flexion-extension arc of less than 100° at latest follow-up or any patient requiring surgical treatment for limited elbow range of motion. ResultsA total of 110 patients with distal humerus fractures were included in the study: 54 patients comprised the elbow stiffness group and 56 patients were in the control group. Average follow-up of 343 (59 to 2,079) days. Multiple logistic regression showed that orthogonal plate configuration (aOR: 5.70, 95% CI: 1.91-16.99, p=0.002), and longer operative time (aOR: 1.86, 95% CI: 1.11-3.10, p=0.017) were independently associated with an increased odds of elbow stiffness. OTA/AO 13A type fractures were significantly associated with a decreased odds of stiffness (aOR: 0.16, 95% CI: 0.03-0.80, p=0.026). Among 13C fractures, olecranon osteotomy (aOR: 5.48, 95% CI: 1.08-27.73, p=0.040) was also associated with an increased odds of elbow stiffness. There were no significant differences in injury mechanism, Gustilo-Anderson classification, reduction quality, days to surgery from admission, type of fixation, as well as rates of ipsilateral upper extremity fracture, neurovascular injury, nonunion, or infection between the two groups. ConclusionDysfunctional elbow stiffness was observed in 49.1% of patients who underwent operative fixation of distal humerus fractures in the present study. Orthogonal plate configuration, olecranon osteotomy, and longer operative time were associated with an increased odds of dysfunctional elbow stiffness; however, 13A type fractures were associated with decreased odds of stiffness. Patients with these injuries should be counseled on their risk of stiffness following surgery, and modifiable risk factors like plate positioning and performing an olecranon osteotomy should be considered by surgeons.

Assessing screw length impact on bone strain in proximal humerus fracture fixation via surrogate modelling.

A high failure rate is associated with fracture plates in proximal humerus fractures. The causes of failure remain unclear due to the complexity of the problem including the number and position of the screws, their length and orientation in the space. Finite element (FE) analysis has been used for the analysis of plating of proximal humeral fractures, but due to computational costs is unable to fully explore all potential screw combinations. Surrogate modelling is a viable solution, having the potential to significantly reduce the computational cost whilst requiring a moderate number of training sets. This study aimed to develop adaptive neural network (ANN)-based surrogate models to predict the strain in the humeral bone as a result of changing the length of the screws. The ANN models were trained using data from FE simulations of a single humerus, and after defining the best training sample size, multiple and single-output models were developed. The best performing ANN model was used to predict all the possible screw length configurations. The ANN predictions were compared with the FE results of unseen data, showing a good correlation (R2 = 0.99) and low levels of error (RMSE = 0.51%-1.83% strain). The ANN predictions of all possible screw length configurations showed that the screw that provided the medial support was the most influential on the predicted strain. Overall, the ANN-based surrogate model accurately captured bone strains and has the potential to be used for more complex problems with a larger number of variables.

Clinical outcomes for linked fixation of distal humerus fractures: a multicenter study

BackgroundO’Driscoll popularized the principle of linked column fixation for distal humerus fractures. Despite the linked column concept being widely accepted, there are few reported techniques to accomplish this goal. A novel device was designed based on the principles of linked columns. An interlocking beam is used to connect the medial and lateral plates, creating a unified fixed angle construct. Our primary objective was to report clinical outcomes across multiple institutions for a linking beam used in distal humerus fracture fixation. MethodsA retrospective series was collected from five institutions for the TiBeam (Skeletal Dynamics, Miami, FL, USA) with a minimum follow-up of six months. Acute and chronic treatment of distal humerus fracture patterns, and all plate configurations were included for analysis. ResultsA total of 36 cases were collected at a mean age of 52 years and a mean follow-up of 19.3 months. AO C-type fractures were 56% of the series. The median MEPS was 85 (IQR 76.3 to 90), the median DASH was 21.4 (IQR 15.9 to 30), and the median VASa was 3.5 (IQR 2 to 5). An olecranon osteotomy was used in 86% of cases and an anatomic plate was used for fixation of the osteotomy in 94% of those cases. There were three cases of olecranon plate removal for a rate across the series of 13.7%. DiscussionOur short-term results demonstrate satisfactory clinical outcomes with low rates of revision for distal humerus fracture fixed with a linking beam. Further, the rate of removal for the olecranon osteotomy plate was lower than historical reports for aggregate methods of osteotomy fixation.

To Compare the Fixation of Distal Humerus Fracture by Orthogonal (90°–90°) Plating Versus Parallel Plating in Adults

Abstract Introduction: A distal humerus fracture is defined as a fracture within a square of the lower end of the humerus where the base is the distance between the epicondyles of the humerus on an anteroposterior view of the radiograph. The most distal humerus fractures are due to high-energy trauma, such as road traffic accidents in adults, and in the elderly due to low-energy injuries, such as trivial falls. The purpose of this study was to analyze and evaluate the comparison of fixation of distal humerus fracture by orthogonal and parallel plating in adults. Materials and Methods: A prospective study was done among 30 patients having distal humerus fractures. The distal humerus fractures were managed with anatomical locking plates by orthogonal and parallel plating techniques through posterior approach and reduction, stable fixation, and functional outcome were assessed by using Mayo Elbow Performance Score (MEPS). Results: The results revealed that all patients were followed up by using MEPS scoring and X-ray of the elbow in anteroposterior and lateral view. In our study, road traffic accidents were the most common mode of injury and the mean age was 43 years. By using the MEPS score, the results were excellent for 9 patients, good for 13 patients, fair for 3 patients, and poor for 5 patients. After comparison between orthogonal and parallel plating groups, there was no significant difference in the total range of flexion and extension, MEPS, and flexion–extension arc. Conclusion: The results conclude that in the management of distal humerus fracture, the plates applied orthogonally have no significant difference compared with the parallel plating technique. The plates applied in the orthogonal and parallel configuration by using appropriate surgical techniques provided stable fixation and anatomical reduction of distal humerus fractures.

Fixation of Lateral Condyle Humerus Fractures in Children by Terminally Threaded Screws

Fixation of Lateral Condyle Humerus Fractures in Children by Terminally Threaded Screws

A Retrospective Analysis of Dynamic Compression Plating Versus Intramedullary Nailing for the Management of Shaft of Humerus Fractures in an Urban Trauma Care Center.

Introduction There is constant debate regarding the best surgical technique for the fixation of shaft humerus fractures. Intramedullary nailing and dynamic compression plating are the most popular surgical options. Materials and methods In our study, we retrospectively analyze the results of 27 patients with shaft humerus fractures managed with intramedullary nailing (10) and dynamic compression plating (17) at our institute from September 2021 to October 2022. Preoperative clinical assessment sheets, postoperative follow-up sheets, operative notes, anesthesia sheets, and preoperative and follow-up radiographs were analyzed. Reamed antegrade nailing was done in all cases, while dynamic compression plating was done through a posterior approach. Results The operative time of the nailing group was 82.1 ± 7.61 mins, which was significantly lesser (P value <0.05) than that of the plating group, which was 119.59 ± 10.16 mins. The intraoperative blood loss of the patients who were managed with nailing was 71 ± 7.38 mL, which was significantly lesser (P value <0.05) than that of the plating group, which was 130.59 ± 11.44 mL. The patients in both groups had a statistically nonsignificant difference in terms of functional results, which were assessed using Rodriguez-Merchan criteria. Complications were similar in both groups with infection (17.65%), and postoperative radial nerve palsy (11.76%) was more common among the patients undergoing plating, and shoulder impingement(20%) was common among those undergoing nailing. Conclusion This study concluded that both surgical options are similar in the case of functional results. The selection of the surgical method should be as per the surgeon's surgical familiarity and personalized to individual patients.

Iatrogenic "overshoot" nerve injuries: imaging features.

Describe features of iatrogenic "overshoot" nerve injuries on ultrasound and MRI, which occur when an instrument passes through the bone and injures the nerve after it penetrates the opposite cortex. After a keyword search of the radiology database at a tertiary care orthopedic hospital from January 2016 to December 2022, those fulfilling the inclusion criteria of (1) instrumentation through the bone during surgery, (2) acute neuropathy immediately after surgery, (3) nerve injury confirmed on electrodiagnostics, and (4) imaging consistent with overshoot nerve injury were included. Imaging studies were retrospectively evaluated to determine primary and secondary signs of an overshoot nerve injury. Six patients (3 females, mean age 26.7 (range 10-49) years) had nerve injury fitting the mechanism of injury: 3 injuries to the radial nerve during fixation of distal humerus fractures, 1 tibial nerve and 1 superficial peroneal nerve injury during fixation of tibial fractures, and 1 posterior interosseous nerve injury during biceps tendon repair. Ultrasounds were performed in all while 4 also had MRI. Secondary signs included (1) cortical defect adjacent to injured nerve (n=2); (2) scar extending from bone to injured nerve (n=2); (3) screw tip pointing to injured nerve (n=1, 4) tract in bone on MRI from previous instrumentation pointing to injured nerve (n=2). In addition to primary signs such as laceration or neuroma, secondary signs of "overshoot" nerve injury include cortical defect, scar extending to nerve, screw tip pointing to nerve, and linear tract in the bone on MRI.

Ultrasound-guided Brachial Plexus Block as a Sole Anaesthetic Technique in a Child for Fixation of Humerus Fracture: A Case Report

Managing supracondylar fractures provides distinct problems in the complex setting of paediatric trauma. A 36-month-old male child was admitted with accidental injury and supracondylar fracture of left humerus. There were no other injuries. The child was planned open reduction and internal fixation in the right lateral position. The plan was to administer nerve block. To satisfactorily transfer the baby, the authors administered 5 mg of oral diazepam to the mother after explanation. The patient was smoothly transferred inside with syrup promethazine 5 mL. After securing an intravenous access, and an intravenous pethidine of 10 mg, he was administered ultrasound guided brachial plexus block with a supraclavicular approach with 5 mL of 0.5% bupivacaine. The pain subsided and the patient slept well. The surgery and the postoperative period were uneventful. The authors concluded that sedating the mother prior will help in separation and nerve blocks can be administered in children in precise sites with the help of ultrasound but without supplemental general anaesthesia. This report is the first case report to do without the use of any intravenous anaesthetic drugs.

Postoperative Opioid Dependence in Patients Undergoing Either Total or Reverse Shoulder Arthroplasty for Proximal Humerus Fracture Fixation.

In elderly patients who have proximal humerus fractures, treatment commonly involves total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA). Following these procedures, patients often require opioids for postoperative analgesia. This common scenario is of clinical and societal importance, as increased postoperative opioid usage has been shown to worsen outcomes and increase the likelihood for dependence. We aimed to compare postoperative opioid use in patients undergoing either TSA or RSA for fixation of their proximal humerus fracture. Specifically, we assessed: (1) postoperative opioid use at two, four, six, eight, and greater than eight weeks postoperatively; (2) aseptic revision rates at 90-days, one year, and two years postoperatively; and (3) periprosthetic joint infection (PJI) rates at 90-days, one year, and two years postoperatively between patients undergoing TSA or RSA for the surgical management of their proximal humerus fractures. For this review, we queried a national all-payer database from October 1, 2015 to October 31, 2020 (n=1.5 million) for all patients who had a "proximal humerus fracture" diagnosis who underwent either TSA or RSA. There were two cohorts: patients undergoing TSA (n=731) and patients undergoing RSA (n=731). Bivariate Chi-square analyses. We found no differences (p>0.05) in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA after two weeks. There was not a significant difference in aseptic revision or PJI rates between the two cohorts (all p>0.05). The evidence comparing opioid use in patients undergoing either TSA or RSA for proximal humerus fracture fixation is lacking. Our study specifically showed no differences in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA.

Comparative study between deltoid split approach versus delto pectoral approach for proximal humerus fracture fixation

Background: Proximal humeral fracture is defined as fractures occurring at or proximal to the surgical neck of the humerus. It affects 2.4% of women over the age of 75 years. It is the commonest fracture affecting the shoulder girdle in adults and its incidence is rising. For displaced fractures that meet surgical indications, deltopectoral approach is the most common approach for plate fixation of proximal humeral fractures. Deltoid splitting approach offers advantages of better exposure and implant placement for fixation of the fracture and early mobilization of the shoulder joint. Methods: This is a comparative study of 30 cases of proximal humerus fractures treated by surgical fixation through deltoid splitting approach and 30 cases treated by delto pectoral approach. Patient of both sexes belonging to adult age group in general population presenting with proximal humerus fracture to the orthopaedic department of Bapuji Hospital and Chigateri General hospital attached to J.J.M. Medical College, Davangere. The period of survey extends from December 2020 to December 2022. The final results were evaluated using constant Murley score periodically. This constant Murley score ranges from 0 to 100 points representing worst and shoulder function respectively. Results: No statistically significant difference was observed in outcome with regard to mechanism of injury, side of fracture and type of fracture with both deltoid splitting approach and delto pectoral approach. Conclusions: The treatment of proximal humeral fractures with a proximal locking plate is reliable using both approaches. No significant difference found in functional outcome of proximal humerus fracture following deltoid split and deltopectoral approach on serial follow up.

Risk Factors for 30-Day Unplanned Re-Operation in Pediatric Upper Extremity Surgery: A National Surgical Quality Improvement Program (NSQIP)-Pediatric Analysis.

Introduction The unplanned re-operation rate has been used as one marker of procedure quality in numerous surgical sub-fields. The purpose of this study was to determine independent risk factors for unplanned re-operations within 30 days following pediatric upper extremity surgery. Methods Pediatric patients who had a primary upper extremity procedure from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. The procedures included percutaneous fixation of supracondylar humerus fractures, open treatment of humeral condylar fractures, tendon sheath incision, repair of syndactyly, and reconstruction of polydactyly. Patients were categorized by those who had unplanned return to the operating room within 30 days and patients who did not. Patient demographics, clinical characteristics, and medical co-morbidities were evaluated for their association with re-operation using bivariate and multivariate analysis. Results A total of 27,536 pediatric patients underwent primary upper extremity surgeries; of these, 290 (1.1%) required an unplanned re-operation. After controlling for potential confounding variables on multivariable regression analysis, American Society of Anesthesiologists (ASA) class III-V (OR 15.89; p<0.001), inpatient procedure (OR 1.29; p=0.044), emergent/urgent triage (OR 3.75; p<0.001), longer operative time (OR 1.01; p<0.001), and prolonged hospital stay (OR 1.01; p=0.010) were independent predictors for re-operation. Conclusion This study demonstrates that the national rate of 30-day unplanned re-operation in pediatric upper extremity surgeries is low overall. The greatest risk factors for unplanned re-operation were ASA class III-V, inpatient setting, emergent/urgent triage, longer operative time, and prolonged hospital stay. This knowledge can help further improve patient outcomes through risk stratification and preoperative planning.

Factors Influencing Functional Outcomes in Supracondylar Humerus Fractures: A Retrospective Study of Paediatric Patients in a Level One Trauma Centre.

Background The outcomes after fixation of the supracondylar humerus fracture (SCHF) are not documented in the current literature. In our study, we endeavour to determine the factors that influence the functional outcome and gauge their respective impact. Methodology We retrospectively reviewed the outcomes of patients who presented to our tertiary care centre (Royal London Hospital) with SCHFs between September 2017 and February 2018. We analysed patient records to assess several clinical parameters, including age, Gartland's classification, comorbidities, time to treatment, and fixation configuration. We conducted a multiple linear regression analysis to determine each of the clinical parameter's impact on the functional and cosmetic outcome, as reflected in Flynn's criteria. Results We included 112 patients in our study. Pediatric SCHFs had good functional outcomes based on Flynn's criteria. There was no significant statistical difference in functional outcomes with respect to sex (p= 0.713), age (p= 0.96), fracture type (p= 0.14), K-wire configuration (p=0.83), and time elapsed since surgery (p= 0.240). Conclusions Our results demonstrate that good functional outcomes can be expected with paediatric SCHFs based on Flynn's criteria, regardless of age at injury, sex, or pin configuration, provided satisfactory reduction is achieved and maintained. The only variable with statistical significance was Gartland's grade; Grades III and IV were correlated with poorer outcomes.

Predictors of Adverse Events in the Surgical Treatment of Adult Distal Humerus Fractures.

The purpose of this study was to identify surgical complications after distal humerus fracture fixation as well as correlations between these complications and patient variables. A total of 132 patients underwent open reduction and internal fixation of traumatic distal humerus fractures between October 2011 and June 2018. Included were adult patients who underwent surgical fixation and had more than 6 months of follow-up. Excluded were patients with inadequate radiographic imaging, less than 6 months of follow-up, and previous distal humerus surgery. Multivariate logistic regression models controlling for age and body mass index were used to determine preoperative factors predictive of postoperative complications. A total of 73 patients were included in this analysis. Surgical complications were reported for 17 patients. Reoperation was required for 13 patients. Open injury at presentation was predictive of delayed union. Predictors of subsequent elbow surgery included younger age, polytrauma, open fracture, and ulnar nerve injury at the time of injury. Radial nerve injury at the time of presentation was also a risk factor for postoperative radial nerve symptoms. Predictors of postoperative heterotopic ossification included older age. Thirty-one patients had an olecranon osteotomy during their open reduction and internal fixation and none went on to nonunion. There were 13 patients with ulnar nerve complications. Of these patients, 3 had undergone an ulnar nerve transposition. None of the other studied variables were predictors of complications, malunion, or nonunion at latest follow-up. Although open reduction and internal fixation is effective in treating distal humerus fractures, its complications cannot be overlooked. Open fractures are more likely to go on to delayed union. Ulnar nerve injury, open fracture, and polytrauma were predictive for reoperation. Older patients were less likely to have subsequent surgery but more likely to develop heterotopic ossification. By identifying at-risk patients, managing physicians can better prognosticate and counsel patients on their recovery. [Orthopedics. 2023;46(6):352-357.].

Inadequate proximal screw fixation increases risk of failure following plate fixation of diaphyseal humerus fractures

BackgroundOperative treatment of humeral shaft fractures (AO/OTA 12) is being performed more frequently. Accordingly, it is important to understand the complications associated with plate fixation. This study analyzes risk factors associated with mechanical failure following plate fixation of humeral shaft fractures in order to further elucidate the mode and location of failure.MethodsA retrospective review of 351 humeral shaft fractures was completed at a single level I trauma center. Eleven of eighty-five humeral shaft fractures had aseptic mechanical failure requiring revision (12.9%), following initial plate fixation. Fracture characteristics (AO type, comminution, location) and fracture fixation (plate type, multiplanar, number of screws proximal and distal to the fracture) were compared between aseptic mechanical failure and those without failure. A forward stepwise logistic regression analysis was performed to determine any significant predictors of aseptic mechanical failure.ResultsThere was significant differences in fixation between the aseptic mechanical failure group and those without failure, specifically in the number of screws for proximal fixation (p = 0.008) and distal fixation (p = 0.040). In the aseptic mechanical failure group, patients tended to have less than < 8 cortices of proximal fixation (82%) and less than < 8 cortices of distal fixation (64%). Conversely, in patients without mechanical failure there was a tendency to have greater than > 8 cortices in both the proximal (62%) and distal fixation (70%). A forward stepwise logistic regression analysis found that less than < 8 cortices of proximal fixation was a significant predictor of aseptic failure, OR 7.96 (p = 0.011). We think this can be accounted for due to the variable bone quality, thinner cortices and multiple torsional forces in the proximal shaft that may warrant special consideration for fixation.ConclusionThe current dogma of humeral shaft fracture stabilization is to use a minimum of 3 screws proximal and distal to the fracture, however the current study demonstrates this is associated with higher rates of mechanical failure. In contrast, 4 bicortical screws or more of fixation on either side of the fracture had lower failure rates and may help to reduce the risk of mechanical failure.Level of Evidence Level III.

Functional outcome of proximal humerus fracture fixation in elderly managed with percutaneous k wire fixation: Observation study of 28 patients

Introduction: Proximal humerus fracture represents the second most common fracture in upper extremity in elderly. Percutaneous fixation has reported to have good functional outcome and has lesser complications rate. In our study we have tried to observe the functional outcome and complication rates of percutaneous fixation for proximal humerus fracture in elderly with Neer type I, II & III. Aim: This study aimed to observe the functional outcome and complication rates of percutaneous fixation for proximal humerus fracture in elderly with Neer type I, II & III.Materials and Methods: This study included 28 patients aged between 55 to 80 years having proximal humerus fracture Neer Type I, II and III presenting to our institute between June 2021 and September 2022. Patients were evaluated clinically and radiological evaluation was done in the form of Xray and CT scan. All patients fulfilling the inclusion criteria were managed with percutaneous K-wire fixation. Post-operative check Xray was done and physiotherapy was advised. Patient were followed up for minimum 10 months and evaluated for radiological union and function outcome using the DASH score. Results: All patients had radiological union in mean 8.2 months. DASH core was used to evaluate shoulder function. DASH score was excellent in 20 patients and was good in 6 patients while it was fair in 2 patients. Out of 28 patients 22 patients did not have any major complications 7 had k wire backout, 2 patients had entry point infection and 1 patient had K-wire migration. Conclusion: K wire fixation of proximal humerus fracture in elderly with Neer type I, II and III, gives a good radiological and functional outcome comparable with other modalities of treatment with low complication rate.

A Dedicated Simulator Training Curriculum Improves Resident Performance in Surgical Management of Pediatric Supracondylar Humerus Fractures.

The primary goal of including simulation in residency training is to improve technical skills while working outside of the operating room. Such simulation-related skill improvements have seldom been measured in the operating room. This is largely because uncontrolled variables, such as injury severity, patient comorbidity, and anatomical variation, can bias evaluation of an operating surgeon's skill. In this study, performance during the wire navigation phase of pediatric supracondylar humerus fracture fixation was quantitatively compared between 2 groups of orthopaedic residents: a standard training group consisting of residents who participated in a single simulator session of wire navigation training and an expanded training group consisting of residents who participated in a dedicated multifaceted wire navigation simulation training curriculum. To evaluate performance in the operating room, the full sequence of fluoroscopic images collected during wire navigation was quantitatively analyzed. Objective performance metrics included number of fluoroscopic images acquired, duration from placement of the first wire to that of the final wire, and wire spread at the level of the fracture. These metrics were measured from 97 pediatric supracondylar humerus fracture pinning surgeries performed by 28 different orthopaedic residents. No differences were observed between the groups for wire spread in the final fluoroscopic images (t(94) = 0.75, p = 0.45), an important clinical objective of the surgery. Residents who received the expanded simulator training used significantly fewer fluoroscopic images (mean of 46 vs. 61 images, t(85) = 2.25, p < 0.03) and required less time from first to final wire placement (mean of 11.2 vs. 14.9 minutes, t(83) = 2.53, p = 0.013) than the standard training group. A post hoc review of Accreditation Council for Graduate Medical Education case logs for 24 cases from the standard training group and for 21 cases from the expanded training group indicated that, at the time of surgeries, residents who received expanded training had completed fewer comparable cases than residents in the standard training group (mean of 13 vs. 21, t(42) = 2.40 p = 0.02). Further regression analysis indicated that the expanded simulator training produced an effect comparable with that associated with completing 10.5 similar surgical case experiences. This study demonstrates that training on a wire navigation simulator can lead to improved performance in the operating room on a critical skill for all orthopaedic residents. By taking fewer images and less time while maintaining sufficient pin spread, simulator-trained residents were objectively measured to have improved performance in comparison with residents who had not participated in the pediatric elbow simulator curriculum. As programs aim to provide safe and effective training for critical orthopaedic skills such as pinning a pediatric elbow, this study demonstrates a simulator curriculum that has demonstrated the transfer of skill from a learning environment to the operating room.

Clinical outcomes of the intramedullary humerus nailing system in the treatment of humerus fractures

&lt;p&gt;&lt;strong&gt;Background&lt;/strong&gt;: After femoral and tibia bone fractures, the humerus fracture is the third long bone fracture. The purpose of this study was to clinically evaluate the outcomes of treating humerus fractures with an KN-5H humerus nailing system. The fixation of humerus fracture especially shaft fractures from intramedullay humeral nail the clinical outcomes obtained from the retrospective study of humerus nailing system on humeral fracture is controversial feature in surgical technical research, follow-up factors, and implants.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;In this retrospective study of KN-5H humerus nailing system (KN-5H intramedullary cannulated humerus nail, KN-5H reconstruction nail, cannulated and KN-5H reconstruction cannulated intramedullary humerus nail) manufactured by the Kaulmed Pvt. Ltd. is used. The total 26 patients from which 11 males and 15 females between the age group of 18-70 years with humerus fracture were taken. Patients didn't received conservative management. The fractures were categorized based on AO classification and Neer type. Th post-operative clinical effectiveness was evaluated using the Radiological evaluation, VAS score and Functional ROM results.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;The mean follow-up period was 15 months (range 13 to 24 months). The mean time of union was 14 weeks (range 10 to 18 weeks) in 26 patients. No non-union occurred in any patients. Functional end results of shoulder and elbow were excellent in 92.3% patients, moderate 5.75% patients and poor in 1.95% patients. Postoperative complications included one superficial infection, 3 patients had nail impingement complain, one patient has shoulder stiffness and had pain in adduction. No implant related complication was reported.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;The treatment of proximal and diaphysis humerus fracture is highly recommended using intramedullary humeral nailing due to lower post-operative complication with high union rate. &lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;

Modern MRI Diagnostics of Upper-Extremity-Related Nerve Injuries-A Prospective Multi-Center Study Protocol for Diagnostics and Follow Up of Peripheral Nerve Injuries.

(1) Background: Peripheral nerve injuries are severe injuries with potentially devastating impairment of extremity function. Correct and early diagnosis as well as regular regeneration observation is of utmost importance for individualized reconstruction and the best possible results. Currently, diagnoses and follow-up examinations are based on clinical examinations supported with electroneurography, which often causes delays in treatment and can result in impaired healing. However, there is currently no diagnostic device that can reliably correlate the anatomic–pathological parameters with the functional–pathological changes initially and during therapy. With new technologies such as MR neurography (MRN), precise visualization of potential nerve damage and visualization of the reinnervation processes is assumed to accelerate clinical decision making and accompaniment of individualized treatment. (2) Methods/Design: This prospective clinical study will examine 60 patients after peripheral nerve lesion aged 18–65 years from trauma timepoint onward. Patients should be observed over a period of 18–24 months with regular clinical examinations, electroneurography, and ultrasound to compare the potential of MRN to current gold-standard diagnostic tools. Furthermore, 20 patients with the same inclusion criteria stated above, with an internal fixation and osteosyntheses of humerus fractures, will be examined to determine the visibility of peripheral nerve structures in close proximity to metal. (3) Discussion: Peripheral nerve injuries are often accompanied with severe, expensive, and long-lasting impairment of extremity function. An early and precise diagnosis of the nerve lesion, as well as the healing course, is crucial to indicate the right therapy as soon as possible to save valuable time for nerve regeneration. Here, new technologies such as MRN aim to visualize nerve injuries on fascicular level, providing not only early diagnosis and therapy decisions, but also providing a precise tool for monitoring of reinnervation processes. As severe injuries of a nerve are often accompanied with bone fractures and internal fixation, we also aim to evaluate the visualization feasibility of nerves in close proximity to metal, and ultimately improve the outcome and extremity function of patients after a peripheral nerve injury.