Fixation Of Humerus Fractures Research Articles

Outcomes following fracture fixation with the Equinoxe® proximal humerus plate: an improvement over PHILOS®?

The purpose of this study is to compare patient outcomes between the Equinoxe® (Exactech, Gainesville, Fla) proximal humerus locking plate and the PHILOS® (Synthes, Paoli, PA) proximal humerus locking plate. Two hundred and seventy-one patients with a displaced proximal humerus fracture presented to our academic medical center between February 2003 and October 2020. Functional outcomes assessed included the Disabilities of the Arm, Shoulder, and Hand questionnaire and shoulder range of motion. Radiographs were utilized to determine fracture healing and development of posttraumatic osteoarthritis or osteonecrosis. Overall, 108 Equinoxe® and 87 PHILOS® patients treated by a single surgeon with complete clinical, functional, and radiographic follow-up were included in the study. Demographics were similar between groups. One hundred and eight Equinoxe® patients healed at a mean time to union by 3.7 ± 2.2months, and 86 PHILOS® patients healed (p = 0.24) by 4.1 ± 2.3months after surgery (p = 0.31). Shoulder external rotation was greater in Equinoxe® patients by 7 degrees (p = 0.044), and forward elevation was greater by 16 degrees (p = 0.005) at one-year follow-up. DASH scores were similar between patients at the 3-, 6-, and 12-month follow-up (p = 0.86, p = 0.77, p = 0.64). Fewer Equinoxe® patients experienced complications (p = 0.043). Fixation of a proximal humerus fracture can safely be performed with both Equinoxe® and PHILOS® proximal humerus locking plates. Patients fixed with Equinoxe® plates achieved a slightly greater degree of external rotation, forward elevation, and experienced fewer complications. This difference may be due to surgeon experience rather than the implant itself.

Fracture location impacts opioid demand in upper extremity fracture surgery

IntroductionOpioid sparing protocols should be formulated with appropriate demand. Specific fracture location has been hypothesized as an important predictor of post-operative pain. The purpose of this study is to evaluate the impact of fracture location on perioperative opioid demand after surgery with the hypothesis that this factor would be significantly associated with perioperative opioid demand in upper extremity fracture surgery. MethodsA national database was used to identify1-month pre-operative to 1-year postdischarge opioid demand in oxycodone 5-mg equivalents in 336,493 patients undergoing fracture fixation of the clavicle through distal radius between 2010 and 2020. Three timeframes were evaluated: 1-month pre-op to 90-days post-discharge, 3 months post-discharge to 1-year post-discharge, and 1-month pre-op to 1-year postdischarge. Multivariable main effects linear and logistic regression models were constructed to evaluate the changes in opioids filled, opioid prescriptions, and odds of two or more opioid prescriptions in these timeframes based on fracture location with adjustment for age, sex, obesity, pre-operative opioid usage, and polytrauma. ResultsCompared to distal radius fracture fixation, fixation of elbow, distal humerus, humeral shaft, and proximal humerus fractures were associated with large, significant increases in 1-month pre-op to 1-year post-discharge opioid filling (33.5 – 63.4 additional oxycodone 5-mg equivalents, all p<0.05) and number of filled prescriptions (0.33 – 0.92 additional prescriptions, all p<0.05) compared to patients with other operatively treated upper extremity injuries. DiscussionFracture location was a significant predictor of perioperative opioid demand. Elbow, distal humerus, humeral shaft, and proximal humerus fracture fixation was associated with the largest increases in opioid demand after upper extremity fracture fixation. Patients with these injuries may be at highest risk of extensive opioid consumption. Level of evidenceLevel III, retrospective, observational cohort study

Response to: Do Obese Children Have Poor Patient-reported Outcomes After Closed Reduction and Percutaneous Pin Fixation of Supracondylar Humerus Fractures?

Response to: Do Obese Children Have Poor Patient-reported Outcomes After Closed Reduction and Percutaneous Pin Fixation of Supracondylar Humerus Fractures?

Do Obese Children Have Poor Patient-reported Outcomes After Closed Reduction and Percutaneous Pin Fixation of Supracondylar Humerus Fractures?

Do Obese Children Have Poor Patient-reported Outcomes After Closed Reduction and Percutaneous Pin Fixation of Supracondylar Humerus Fractures?

A Standardized Order-Set Improves Variability in Opioid Discharge Prescribing Patterns After Surgical Fixation of Pediatric Supracondylar Humerus Fractures

To evaluate institutional opioid prescribing patterns following percutaneous fixation of pediatric supracondylar humerus fractures before and after implementation of a standardized discharge order set. A retrospective review of patients who underwent closed reduction and percutaneous skeletal fixation of a Type II or III supracondylar humerus fracture in 2017 (prior to pain protocol implementation) and again in 2019 (after pain protocol implementation) SETTING: Single Tertiary Care Children's Hospital PARTICIPANTS: In total, 106 patients met inclusion criteria between years 2017 (n = 49) and 2019 (n = 57). Exclusion criteria included miscoded patients, open fractures, patients who presented with vascular injury or nerve palsy, polytrauma patients with multiple fractures in the same upper extremity, and supracondylar humerus fractures that underwent an open procedure. There were no significant differences between inpatient pain scores (p = 0.91) and MDE prescribed (p = 0.75) between the 2 cohorts. In 2017, large variability was noted in day supply of opioids (0-11.4 days) and MDE (0-8.45 mg/kg), with significant differences between prescribing patterns of junior and senior level residents (mean day supply of opioids (p = 0.045), mean MDE prescribed on discharge (p = 0.001)). After implementation of a standardized opioid discharge order set, there was a tenfold increase in the number of patients discharged without an opioid prescription (2017: 4%, 2019: 44%). Additionally, any discrepancies between prescribing practices of junior and senior level residents were eliminated (mean day supply of opioids (p = 0.65), mean MDE prescribed on discharge (p = 0.69)). The introduction of a standardized post-operative opioid discharge order set led to a 10-fold increase in the number of patients discharged without an opioid prescription. Additionally, the order set decreased the variability in the prescribing patterns of discharge opioid medications without change in pain control. The resident prescribing variability based upon level of experience resolved with the use of the order set.

Do Obese Children Have Poor Patient-reported Outcomes After Closed Reduction and Percutaneous Pin Fixation of Supracondylar Humerus Fractures?

Nearly 1 in 5 American children are obese. The primary purpose of this study is to evaluate the relationship between childhood obesity and perioperative complications, patient-reported outcomes (PRO), and functional recovery after closed reduction and percutaneous pinning (CRPP) of type II and III supracondylar humerus fractures. Retrospective review of patients treated operatively with CRPP of Wilkins modification of the Gartland classification type II and III supracondylar humerus fractures was performed over a 1-year timeframe (July 1, 2016 to July 1, 2017). One hundred forty-four patients under the age of 16 treated were identified. Obesity was defined as body mass index (BMI) at or above the 95th percentile for age. Obesity as a risk factor for poor outcomes was assessed. The primary outcome measure was postoperative PRO [quick-DASH, Patient Reported Outcomes Measurement Information System (PROMIS)-UE, PROMIS Global Health, and PROMIS Pain scores]. Mean age at surgery was 5.9 years (SD=2.1, 1.07 to 12.2) and mean age at final follow-up (3.3 y) was 8.8 (SD=2.14, 4 to 16). Mean patient BMI was 17.2 (SD=4.48, 12.4 to 56.2). Sixty-six patients were female (45.8%) and 78 patients were male (54.2%). In all, 31 of 144 patients (21.5%) met criteria for obesity. Obesity (95th percentile for BMI or above) was not associated with a higher rate of complications overall (χ2=1.29, P=0.256), range of motion loss (χ2=0.2, P=0.655) or requirement of postoperative physical therapy (χ2=0.17, P=0.678). Seventy-five patients were available and willing to participate in the outcomes score assessments. Mean follow-up for this cohort of 75 patients was 3.3 years (SD=0.31, 2.85 to 3.88). There were no differences in PROMIS pain, PROMIS upper extremity function, PROMIS general health, or quick-DASH scores when comparing obese with nonobese patients. Obesity is a growing concern in the United States and its effect on long-term outcomes after CRPP of supracondylar humerus fractures is unknown. The present study demonstrates no difference in complications or PRO among obese patients compared with nonobese patients. Level IV-retrospective cohort study.

Surgery or Conservative Treatment of Forearm in Patients Diagnosed with Pediatric Floating Elbow? Retrospective Analysis of 60 Consecutive Cases.

The coexistence of supracondylar humerus fracture and forearm fracture is a rare trauma (3-13%) and it is called floating elbow. The aim of this study is to clinically compare the treatment outcomes of the patients diagnosed with floating elbow who underwent surgical treatment and who were followed up forearm with immobilization with splint. When scanned retrospectively, 60 patients who were treated with the diagnosis of floating elbow due to traumatic causes and followed up for at least 1year were included in our study. Surgical treatment was performed on 42 patients for forearm fracture. Eighteen patients followed up with immobilization with a long arm splint. The results were evaluated according to the criteria modified by Templeton and Graham, in comparison with the patient's intact side. In the patients whose forearms were followed up conservatively, the mean age was 5.67 ± 2.25years, and the mean follow-up period was 62.17 ± 45.91months. In the patients who underwent surgery for the forearm, the mean age was 8.79 ± 2.01years, and the mean follow-up was 47.14 ± 34.25months. Eighteen patients whose forearms followed up conservatively, 12 had excellent and good clinical results and 6 had poor and moderate clinical results. Excellent and good clinical results in 27 patients who underwent surgical treatment for their forearms, moderate and poor clinical results obtained in 15 of them. There was no significant difference between the two groups (p = 0.357). In conclusion, satisfactory clinical and radiological outcomes can be obtained with immobilization of the forearm fracture with splint, if acceptable reduction can be provided for the forearm following fixation of the supracondylar humerus fracture with the K-wire for treatment of floating elbow injury.

The effect of the angle between fracture line and Kirschner wires on stability in supracondylar humerus fractures treated with Kirschner wire fixation: A finite element analysis.

Objectives This study aims to investigate the effects of the angles created by the Kirschner wires (K-wires), which are applied in the percutaneous fixation of supracondylar humerus fractures with cross K-wire, with the fracture line on fracture stabilization.Patients and methods The study was conducted on distal humerus fracture models. Medial and lateral K-wires were placed in the fracture models. The angle between the fracture line and the K-wire inserted from medial was represented by alpha (α), while the angle between the fracture line and the K-wires inserted from lateral was represented by beta (β). A combination of various angles (30°, 45°, and 60°) was used in each model, where no two models had the same combination of α and β, resulting in nine different wire configurations. The simulation program was used to simulate the effects of forces, which were applied on rotation, flexion and extension directions, on these models. We measured and compared the stress on the wires and the displacement of fractures under different force configurations.Results When the force was applied in the counterclockwise direction, the stresses were 58 megaPascal (MPa) on medial K-wire, 24 MPa on lower lateral K-wire, and 45 MPa on upper lateral K-wire in (45°, 45°) wire configuration. When the force was applied in the clockwise direction, the stresses were 57 MPa on medial K-wire, 23 MPa on lower lateral K-wire, and 45 MPa on upper lateral K-wire in (45°, 45°) wire configuration. In all models, the increased α and β angles were translated into the decreased stress on K-wires at the fracture level and decreased displacement under rotational deforming forces. Despite having generally lower fracture displacement, the increased α and β angles led to variable changes in the stress on K-wires against flexion and extension forces.Conclusion In supracondylar humerus fractures, increasing the insertion angle of both medial and lateral K-wires augments stabilization and reduces displacement, particularly against rotational deforming forces.

Functional and Radiological Outcome in Distal Third Humerus Fracture Treated with Extra-articular Locking Plate: A Multicentric Retrospective Study.

Introduction:The optimal method for fixation of extra-articular distal humerus fractures poses a management dilemma. Although various plate configurations have been proposed, anatomic shaped extra-articular distal humerus locking plates (EADHPs) have emerged as a viable solution for these complex injuries. We assessed functional and radiologic outcomes in our retrospective case series of extra-articular distal humerus fractures managed with these plates at different centers in Cuttack, Odisha.Materials and Methods:One hundred and ten patients of extra-articular distal humerus fractures, who were operated at various trauma centers between January 2012 and December 2020, were identified. After exclusion, 100 patients were available for the final assessment. All patients were operated with the triceps-reflecting modified posterior approach. Regular functional–radiologic follow-up was done evaluating elbow functionality, fracture union, secondary displacement, nonunion, implant failure, and any complications; Mayo Elbow Performance Score (MEPS) was used for the final functional assessment.Results:Sixty-seven percent of male and 33% of female patients constituted the study group, who had an average follow-up of 18 months. Preoperatively three patients and postoperatively one patient had radial nerve palsy; all had neurapraxia and recovered completely. Overall, 95% of patients were adjudged to have complete radiological union within 3 months; 6% of patients developed nonunion. The mean flexion achieved was 123 + 22, and the mean extension was 4.031 + 6.50; five patients with head injury developed flexion deformity of 45. The average MEPS at the final follow-up was 91 + 9.8.Conclusion:Stable reconstruction and early initiation of physiotherapy are utilitarian to envision optimal outcome; the use of precontoured EADHPs has yielded satisfactory results with minimal complications in our hands.

Distal humerus dual plating with triceps tongue technique: A case series

Background: Fixation of intra-articular distal humerus fractures has remained a challenge to orthopaedic surgeons due to complicated anatomy of elbow, comminution at fracture site and osteopenia of articular surfaces. We aimed to evaluate the functional outcomes and complications after dual plating for distal humerus fractures with triceps tongue technique. Material and methods: We conducted a retrospective study which consisted of 20 cases of distal humerus fracture with intraarticular extension and treated with open reduction and internal fixation with dual column plating using triceps tongue technique. Triceps Tongue approach allows exposure of distal humerus articular surface by forming an inverted V-shaped flap of distal triceps at the musculotendinous junction. Results: Union was achieved in all cases. Mean time of fracture union was 12.55±1.82 weeks. There was no case of non-union although elbow stiffness occurred in one patient. The mean MEPS score was 84.45±8.18 with a range of 70-96. Conclusion: Triceps Tongue approach is a simple and less technically demanding approach for the surgeon that can be used in management of the majority of the distal humeral fractures, giving adequate exposure of the surgical field, aiding in proper reduction of fracture fragments and thus obviating the need for an olecranon osteotomy.

Functional outcome of type 13 C2 distal humerus fractures treated with precontoured locking plates

Background: Distal humerus fractures pose the most challenging task in treatment, which can lead to poor functional outcomes. Anatomic reduction and internal fixation, along with early mobilization, are predicted to improve the functional outcomes. To evaluate the functional outcome, rate of malunion, and intercondylar fixation of distal humerus fractures treated with anatomically precontoured locking plates.Methods: Thirty patients of either sex admitted with type 13 C2 distal humerus fractures, were included in this prospective study. All patients underwent open reduction and internal fixation with anatomically precontoured locking plates and screws using the modified triceps tongue flap approach. Postoperatively, patients were followed up for 6 months. During follow-up, they were evaluated clinically, radiologically, and functionally by mayo elbow performance score (MEPS). The results were analyzed using Chi-square test.Results: A majority of the injuries were seen in males (66.7% vs. 33.3%). The mean age was 36.9 ± 14.7 years. The common mode of injury was through road traffic accident (66.7%). The right upper limb (76.7%) was the most common side involved. The overall excellent/good scores, according to the MEPS, were observed in 80% of the patients. The average time taken for the radiological union at the fracture site was 10.2 ± 2.1 weeks. The mean arc of extension-flexion at 6th weeks was 32.1°–104.1° and at 6th months was 11.5°–124.2°. The complications were early superficial infection (3.3%), ulnar neuropraxia (3.3%), delayed union (3.3%), malunion (3.3%), and chronic osteomyelitis (3.3%).Conclusion: Distal humerus fractures treated with anatomically precontoured locking plates was effective in preserving the functional outcome of the elbow.

Brachial artery injury with humerus fracture caused by pig bite: A case report

Animal bite causing vascular injury is not uncommon. We present a rare case of brachial artery injury with humerus fracture in a five year old child, injury caused by domestic pig bite. Early surgical intervention is key to success in such cases. A five year old boy presented with brachial artery injury with humerus fracture following domestic pig bite. Immediate surgical intervention in form of open reduction and internal fixation of humerus fracture and brachial artery thrombectomy with repair saved his upper extremity.

How Many Proximal Screws Are Needed for a Stable Proximal Humerus Fracture Fixation?

Purpose:This biomechanical study investigates the optimal number of proximal screws for stable fixation of a 2-part proximal humerus fracture model with a locking plate.Methods:Twenty-four proximal humerus fracture models were included in the study. An unstable 2-part fracture was created and fixed by a locking plate. Cyclic loading and load-to-failure tests were used for the following 4 groups based on the number of screws used: 4-screw, 6-screw, 7-screw, and 9-screw groups. Interfragmentary gaps were measured following cyclic loading and compared. Consequently, the load to failure, maximum displacement, stiffness, and mode of failure at failure point were compared.Results:The interfragmentary gaps for the 4-screw, 6-screw, 7-screw, and 9-screw groups were significantly reduced by 0.24 ± 0.09 mm, 0.08 ± 0.06 mm, 0.05 ± 0.01 mm, and 0.03 ± 0.01 mm following 1000 cyclic loading, respectively. The loads to failure were significantly different between the groups with the 7-screw group showing the highest load to failure. The stiffness of the 7-screw group was superior compared with the 6-screw, 9-screw, and 4-screw groups. The maximum displacement before failure showed a significant difference between the comparative groups with the 4-screw group having the lowest value. The 7-screw group had the least structural failure rate (33.3%).Conclusion:At least 7 screws would be optimal for proximal fragment fixation of proximal humerus fractures with medial comminution to minimize secondary varus collapse or fixation failure.Level of Evidence:Basic science study.

Prediction of the location of radial nerve in arm to avoid iatrogenic injury: Cadaveric study in Indian population

Background: The radial nerve arises from posterior cord of brachial plexus and descends distally to spiral groove, our aim is to study upper and lower margins of groove with respect of bony landmark like posterolateral aspect of Acromian process, medial and lateral epicondyle of humerus, which helps to identify radial nerve during humerus fracture fixation surgery and hence will reduce iatrogenic radial nerve injury.Methods: Twenty formalin preserved cadaveric upper limbs obtained from anatomy department of Government medial collage, Surat. Dissection done, Radial nerve isolated from low triangular space to lateral inter muscular septum and various measurements done for each specimen.Result: Without sex or age differentiation the results of this study are: The mean humeral length was 30.6 ± 1.86 cm. Mean Distance of medial epicondyle to entry of radial nerve into spiral groove was 18.3±1.48 cm. Mean Distance of lateral epicondyle to exit of radial nerve into spiral groove was 11.49±1.46 cm. The mean length of radial nerve groove/spiral groove was 4.29±1.28 cm.Conclusion: Radial nerve is at the risk of injury with fracture & fixation in two areas. First along the spiral groove & second along the lateral aspect of humerus in distal third from proximal to lateral epicondyle to level of proximal aspect of metaphyseal flare. Our study has identified the point of intersection of radial nerve to humerus in Indian population. Understanding the safe zones and zone of danger of humerus provide more safety during surgical interference of humerus. To do this, radial nerve must be identified and protected. Wide incision and blunt dissection is still recommended to minimize the risk of radial nerve damage.

Functional outcome of the treatment of AO-ASIF type C distal humerus fracture using Lambda plate

Introduction: Although the use of two plates for the treatment of type-C distal humerus fracture is popular, site of plate placement still is under debate. Use of Lambda plate for the fracture treatment can be easier and settle the dispute. This study aims to evaluate the functional outcome of the surgery using Lambda Plate. This can be a reference for surgeons and helps them make the decision about choice of implant for type C distal humerus fracture treatment among Nepalese people.&#x0D; Methods: This interventional study used Lambda plate for the treatment of type C fracture of distal humerus. Patients were examined at 4, 12, and 24 weeks respectively for the measurement of the outcome. Visual analogous scale was used for assessment of pain, range of motion for functional recovery and Mayo Elbow Performance Score was used for the assessment of functional outcome. Paired-samples t-test and linear regression was used to for data analysis.&#x0D; Results: Functional outcome at the last follow-up was excellent in 24(53.33%) patients, good in 18(40%) patients and fair in 3(6.67%) patients. Range of motion of elbow increased significantly with every follow-up (p-value &lt;0.001). Average angle of flexion at last follow-up was 117.53°±11.74 while loss of extension was 7.53°±4.86. Average number of patients had their fracture union at 19.84±2.38 weeks. There was no association of age, sex and union weeks with functional outcome when measured with MEPS.&#x0D; Conclusion: Fixation of distal humerus fracture by using Lambda plate gave excellent and satisfying outcome in terms of pain, range of motion and objective functional outcome.

Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of proximal humerus fractures.

HypothesisWe hypothesized that the modified Fragility Index (mFI) would predict complications in patients older than 50 years who underwent operative intervention for a proximal humerus fracture.MethodsWe retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a proximal humerus fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates as well as length of stay (LOS) were recorded. Univariate as well as multivariable statistical analyses were performed, controlling for age, sex, body mass index, LOS, and operative time.ResultsWe identified 2,004 patients (median age, 66 years; interquartile range: 59-74), of which 76.2% were female. As mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 2.8% to 6.7% (P-value = .005), rate of discharge to rehabilitation facility increased from 7.1% to 25.3% (P-value < .001), and rates of any complication increased from 6.5% to 13.9% (P-value < .001). Specifically, the rates of renal and hematologic complications increased significantly in patients with mFI of 2 or greater (P-value = .042 and P-value < .001, respectively). Compared with patients with mFI of 0, patients with mFI of 2 or greater were 2 times more likely to be readmitted within 30 days (odds ratio = 2.2, P-value .026). In addition, patients with mFI of 2 or greater had an increased odds of discharge to a rehabilitation center (odds ratio = 2.3, P-value < .001). However, increased fragility was not significantly associated with an increased odds of 30-day reoperation or any complication after controlling for demographic data, LOS, and operative time.ConclusionAn increasing level of fragility is predictive of readmission and discharge to a rehabilitation center after open reduction and internal fixation of proximal humerus fractures. Our data suggest that a simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures.

Comparison of outcome of distal humerus fracture: Single extra articular humerus plating versus bipillar plating

Introduction: Distal humerus fractures are complex injuries as their management requires stable fixation and properly working adjoining joints. Management includes open reduction and internal fixation of distal humerus fractures with the use of available implants and their modification. Dual lock plating still has disadvantages of less hardware availability, their cost and also long surgical time wiht extensive soft tissue damage. The mainstay objective of this study is to evaluate the effectiveness and benefits of distal humerus fractures operated by using a single extra articular humerus plating versus bipillar plating. Aims and Objectives: 1: Evaluation of Clinical and radiological Outcome of single extra articular humerus plating planned for distal humerus fractures. 2: Comparison of clinical outcome of single extra articular humerus plating than the bipillar plating planned for distal humerus fractures. Materials and Methods: A retrospective clinical study was done on 40 patients with distal humerus fractures treated with single extra articular humerus plating and bipillar plating by trained single surgeon at a tertiary trauma care centre in the Department of Orthopaedics, BJ medical college, Civil hospital Ahmedabad between August 2016 and march 2018. The mean follow-up study time was approximately 13 months. Observation and Results: All the operated patients were followed up for a mean time of about 13 months (range from 06 to 20 months). Clinical, physiological and ortho-radiological assessment was performed to observe and evaluate fracture stabilization and reduction and fracture healing and callus formation and range of movements. The Mayo Elbow Performance Score and visual analogue scale were used to asses functional outcome. Conclusion: Proper Reduction with internal fixation still being considered the gold standard for treatment of distal humerus fractures. Extra articular plating however has better good prognostic results than bipillar plating. Early p

Skinny wire and locking plate fixation for comminuted intra-articular distal humerus fractures: a technical trick and case series

Intra-articular distal humerus fractures present a challenge to orthopedic surgeons. Stable fixation is difficult to achieve in fractures with articular and metaphyseal comminution and osteoporotic bone. Hence, these fractures are more commonly being managed with total elbow arthroplasty. We describe a novel surgical technique that confers stable fixation, allowing for early range of motion resulting in a high rate of union, a functional range of motion, and excellent patient reported outcome scores without the activity restrictions of total elbow arthroplasty. Retrospective case series of 30 patients with AO/OTA type B and C intra-articular distal humerus fractures who underwent ORIF from 2014-2019 utilizing a novel surgical technique that focuses on reconstructing a comminuted articular surface through meticulous, transverse fixation of the tiny articular fragments with long, thin Kirchner wires, which are then bent over and trapped under locking compression plates to create a fixed angle support to the metadiaphysis. Patient mean age of 59 (19-90) years and 61% were female. Median follow up was 1.2 years. Twenty-seven (87%) were type C fractures and 3 (13%) were type B. Five patients (16%) suffered a concurrent ipsilateral upper extremity injury and four (13%) had an open fracture. Two were polytrauma patients. All fractures healed with an average time to union of 11 weeks. Over 80% patients reported no or mild pain at final follow up. Mean arc of elbow motion was 102 degrees, mean QuickDASH score 25.2. Post-operative complications included ulnar nerve paresthesias (38%), wound infection (3.2%), heterotopic ossification (3.2%), and olecranon nonunion (3.2%). Eight patients underwent secondary procedures: 7 (23%) removal hardware, 3(9.6%) capsular release, 2 (6.4%) ulnar nerve transpositions, and 1 (3.2%) total elbow arthroplasty. We describe a novel surgical technique that we believe results in strong, stable fixation of complex intra-articular distal humerus fractures irrespective of bone quality. In our series, all fractures healed and post-operatively patients reported low levels of pain, achieved excellent elbow range of motion, high patient reported outcome scores. Patients should be counseled about high rates of post-operative ulnar nerve paresthesias that can be expected to improve over time and high reoperation rates for symptomatic hardware.

Inclusion of Olecranon Osteotomy With the Posterior Approach for Fixation of Distal Humerus Fractures (OTA/AO 13) Does Not Increase Surgical Complications.

To determine if inclusion of an olecranon osteotomy to the posterior paratricipital approach for operative fixation of distal humerus fractures significantly affects surgical complication rates (OTA/AO 13). Retrospective comparative cohort study. Level 1 trauma center. Three hundred four patients underwent open reduction internal fixation of a distal humerus fracture between 2007 and 2017. Of those, 134 met inclusion criteria (≥15 years, OTA/AO fracture type 13A, B, or C, and posterior surgical approach) for the study (n = 64 with olecranon osteotomy; n = 70 without olecranon osteotomy). Open reduction internal fixation of distal humerus fractures performed using a posterior paratricipital approach with or without olecranon osteotomy. Ulnar neuropathy (UN), fracture site bony nonunion, and surgical site infection (SSI). Thirty-one (33.3%) who underwent the paratricipital approach without olecranon osteotomy, and 15 patients (26.8%) who underwent olecranon osteotomy reported postoperative UN with no significant difference between approaches (P = 0.438). There was no significant difference in rates of SSI (P = 0.418) or fracture site nonunion (P = 0.263) when comparing the approaches. Subjects with Charlson comorbidity index ≥2 were more likely to not undergo an olecranon osteotomy (P = 0.01), whereas subjects with more complex fractures by OTA/AO classification were more likely to have an olecranon osteotomy approach (P = 0.001). Addition of an olecranon osteotomy with the paratricipital approach for fixation of distal humerus fractures does not result in higher rates of UN, fracture site nonunion, or SSI. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Novel Technical Factors Affecting Proximal Humerus Fixation Stability.

Intra-articular screw cut-out is a common complication after proximal humerus fracture (PHF) fixation using a locking plate. This study investigates novel technical factors associated with mechanical failures and complications in PHF fixation. A retrospective radiological study. Level 1 trauma center. Clinical and radiological data from consecutive PHF patients treated between January 2007 and December 2013 were reviewed. Open reduction and internal fixation with the Synthes Philos locking plate. Postoperative radiographs were assessed for quality of initial reduction, humeral head offset, screw length, number and position, restoration of medial calcar support or the presence of calcar screws, and intra-articular screw perforations. Using SliceOMatic software, we validated a method to accurately identify screws of 45 mm or longer on AP radiographs. Follow-up radiographs were reviewed for complications. Among 110 patients included [mean age 60 years, 78 women (71%), follow-up 2.5 years] and the following factors were associated with a worse outcome. (1) Screws >45 mm in proximal rows [Odds Ratio (OR) = 5.3 for screw cut-out); (2) lateral translation of the humeral diaphysis over 6 mm (OR = 2.7 for loss of reduction); (3) lack in medial support by bone contact (OR = 4.9 for screw cut-out); (4) varus reduction increased the risk of complications (OR = 4.3). The importance of reduction and calcar support in PHF fixation is critical. This study highlights some technical factors to which the surgeon must pay attention: avoid varus reduction, maximize medial support, avoid screws longer than 45 mm in the proximal rows, and restore the humeral offset within 6 mm or less. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.