Humeral Midshaft Research Articles

Prospective comparative study between antegrade interlocking undreamed nail versus compression plate fixation of acute closed humeral mid third shaft humerus in adults

Objective: To assess the functional outcome, time to union, shoulder pain, blood loss, operative time, iatrogenic radial nerve injury, hospitalization, and infection. Methodology: It is a prospective randomized study on 30 patients with mid-shaft humerus fracture according to AO classification (1.2A1, 2, 3 and 1,2B) with functioning radial nerve. They were randomly dividing into two groups. Group A were treated by a closed antegrade interlocking nail, and group B treated by open reduction and locked compression plate fixation. The follow-up was up to 6 months, including time to union, shoulder pain, intraoperative blood loss, operative time and iatrogenic radial nerve injury. Functional outcome was assessed by quick DASH score. Results: Road traffic accident was the main cause of trauma (70%). The average time to union were statistically not different in both groups. Quick DASH score was good in both groups and statistically not significant. Shoulder pain in group A was (40%), while none patient in group B (p>0.017). The operative period time, mean hospital stays, and blood loss of group B were significantly higher than in group A Conclusion: Nailing is minimally invasive, has less infection rate, iatrogenic nerve injury, operative time, intraoperative blood loss, and hospitalization.

Clinical results of antegrade intramedullary nailing for humeral midshaft pathological fractures

Clinical results of antegrade intramedullary nailing for humeral midshaft pathological fractures

Ontogenetic and morphological variation in primate long bones reflects signals of size and behavior.

Many primates change their locomotor behavior as they mature from infancy to adulthood. Here we investigate how long bone cross-sectional geometry in Pan, Gorilla, Pongo, Hylobatidae, and Macaca varies in shape and form over ontogeny, including whether specific diaphyseal cross sections exhibit signals of periosteal adaptation or canalization. Diaphyseal cross sections were analyzed in an ontogenetic series across infant, juvenile, and adult subgroups. Three-dimensional laser-scanned long bone models were sectioned at midshaft (50% of biomechanical length) and distally (20%) along the humerus and femur. Traditional axis ratios acted as indices of cross-sectional circularity, while geometric morphometric techniques were used to study cross-sectional allometry and ontogenetic trajectory. The humeral midshaft is a strong indicator of posture and locomotor profile in the sample across development, while the mid-femur appears more reflective of shifts in size. By comparison, the distal diaphyses of both limb elements are more ontogenetically constrained, where periosteal shape is largely static across development relative to size, irrespective of a given taxon's behavior or ecology. Primate limb shape is not only highly variable between taxa over development, but at discrete humeral and femoral diaphyseal locations. Overall, periosteal shape of the humeral and femoral midshaft cross sections closely reflects ontogenetic transitions in behavior and size, respectively, while distal shape in both bones appears more genetically constrained across intraspecific development, regardless of posture or size. These findings support prior research on tradeoffs between function and safety along the limbs.

Treatment of nonunions of the humeral shaft with nonvascularized fibular strut allograft: postoperative outcomes and review of a surgical technique.

HypothesisPersistent humeral shaft nonunions result in continued pain and disability of the affected arm and are difficult to treat even with several surgical procedures and locked plating. A fibular allograft provides bony purchase for fixation as well as rotational stability and bridging of nonunion defects.MethodsWe conducted a retrospective review of a single surgeon’s clinical practice between July 1995 and January 2011. The inclusion criteria were patients aged ≥ 18 years who underwent revision surgery for a humeral shaft nonunion by open reduction and revision internal fixation with a supplementary fibular strut allograft.ResultsThirteen patients who met the inclusion criteria were evaluated with physical examinations, validated functional outcome measures, and radiographs to assess union rates. The mean follow-up period was 7.5 years (range, 0.5-15.6 years); there were 11 women (85%) and 2 men (15%). Of the patients, 3 (23%) had proximal-third nonunions, 7 (54%) had middle-third nonunions, and 3 (23%) had distal-third nonunions. After revision surgery with fibular allograft, 10 of 13 patients went on to achieve healing, giving a union rate of 76.9%. The mean postoperative Disabilities of the Arm, Shoulder and Hand score was 38.1 points (standard deviation [SD], 27.6 points). The mean Constant score was 55.2 points (SD, 24.0 points), representing a 62% return of function compared with the contralateral side. The mean postoperative American Shoulder and Elbow Surgeons score was 65.4 points (SD, 28.5 points), and the average visual analog scale pain score (out of 10) was 2.1 (SD, 3.3) at final follow-up.ConclusionFibular allograft is an effective and straightforward option for treating humeral midshaft and distal-shaft nonunions; however, treatment of proximal-third nonunions remains challenging.

Comparison of the Posterior and Anterolateral Surgical Approaches in the Treatment of Humeral Mid-Shaft Fractures: A Retrospective Study.

BackgroundThe aim of this study was to retrospectively assess and compare the functional outcomes and complications following anterolateral versus posterior surgical approaches for the treatment of mid-shaft fractures of the humerus.Material/MethodsThis study included 107 patients treated for mid-shaft fractures between May 2015 and July 2018. Demographic and surgical data were collected for each patient. During follow-up visits, radiographs were acquired and evaluated. The clinical outcomes of the involved joints were assessed by the Constant scoring system, range of motion (ROM), and the Mayo Elbow Performance Scoring system at the 12-month follow-up.ResultsThe posterior approach was performed in 57 patients with type A fractures (group I, n=28) and type B or C fractures (group III, n=29). The anterolateral approach was performed in 50 patients with type A fractures (group II, n=32) and type B or C fractures (group IV, n=18). There were no significant differences between group I and group II nor between group III and group IV with respect to patient demographic data, surgical data, Constant score, ROM, or Mayo Elbow Performance score. A significant difference in the total complication rate was observed between group I and II.ConclusionsThe anterolateral approach showed an advantage over the posterior approach for treating simple humeral mid-shaft fractures. However, this advantage was not observed in treating comminuted fractures.

A histological study of normal and pathological limb regeneration in the Mexican axolotl Ambystoma mexicanum.

Salamanders show unparalleled capacities of tissue regeneration amongst tetrapods (four-legged vertebrates), being able to repair and renew lost or damage body parts, such as tails, jaws, and limbs in a seemingly perfect fashion. Despite countless studies on axolotl (Ambystoma mexicanum) regeneration, only a few studies have thus far compared gross morphological and histological features of the original and regenerated limb skeleton. Therein, most studies have focused on nerves or muscles, while even fewer have provided detailed information about bones and cartilage. This study compares skeletal tissue structures of original and regenerated limbs with respect to tissue level histology. Histological serial sections of 55 axolotl larvae were generated, including 29 limbs that were severed by conspecifics, and 26 that were subject to targeted amputations. Amputations were executed in several larval stages (48, 52, and 53) and at different limb positions (humeral midshaft, above the mesopod). In addition, 3D reconstructions were prepared based on X-ray microtomography scans. The results demonstrate that regenerated forelimbs show a diversity of limb and digit abnormalities as a result of imperfect regeneration. Furthermore, abnormalities were more severe and more frequent in regenerated forelimbs caused by natural bites as compared with regenerated forelimbs after amputation. The results indicate that abnormalities occur frequently after regeneration in larval axolotls contradicting the notion of regeneration generally resulting in perfect limbs.

Ontogenetic changes of tissue compartmentalization and bone type distribution in the humerus of Soay sheep.

We studied ontogenetic changes of histomorphological features and bone type distribution in the humeral midshaft region of Soay sheep from three postnatal age classes (13, 25, and 33months). Our study demonstrated a marked change of bone type distribution in the humeri with age. In the cortical midshaft region of 13-month-old individuals, periosteal fibrolamellar bone was the dominating bone type. This indicates a rapid bone growth during the first year of life, which was only interrupted by a seasonal growth arrest in the animals' first winter. In individuals from the two older age classes, periosteal lamellar-zonal bone and intermediate fibrolamellar bone had been formed at the periosteal surface, and endosteal lamellar-zonal bone at the endosteal surface. These bone types are indicative of a reduced bone growth rate. A marked reduction in radial growth was already recorded in the 25-month-old individuals. Distribution and extent of secondary bone showed a marked bilateral symmetry in the humeri of individual sheep. The presence of secondary bone was largely restricted to the anterior (cranial) and the medial cortical areas. This characteristic distribution of remodeling activity within the humeral cortex of sheep is consistent with the view that remodeling activity is largely caused by compressive stress. Our study further demonstrated the presence of a considerable cortical drift in the sheep humeri over the study period, with endosteal resorption occurring predominantly in the posterior (caudal) quadrant and formation of a prominent endosteal lamellar pocket in the anterior (cranial) and medial cortical quadrants.

Comparative study of results of ORIF with plating vs. CRIF with nailing in fracture midshaft humerus

Background: Fractures of the humeral mid shaft are common. The advantages of operative management are early mobilization and patient comfort but, operative management carries the risk of technical errors and post-operative complications like infections and nerve injuries. Aims and Objectives: To study the fracture pattern and surgical management of fracture midshaft humerus by intramedullary nailing and plating. Materials and Methods: Forty eight patients were studied in the Department of Orthopaedic, MLB Medical College Jhansi from August 2018 to August 2019, after randomizing them into plating or interlocking nailing. A thorough history and clinical examination was done. Once the patients were randomized, pre-operative planning and investigations were done and the patients were posted for open reduction and internal fixation with plating or interlocking nailing. The patients were followed up every second week till radiological union was seen. The functional outcome was measured by the “Disabilities of Arm, Shoulder and Hand” (DASH) Questionnaire at nine months or at full recovery which ever was earlier. Result: Out of 60 fractures shaft of humerus, 48 were operated and the rest 12 treated conservatively. Mean time taken for radiological healing in the interlocking group was 14.05 and in plating was 16.06. The mean DASH score in the plating group was 24.1 and in the interlocking group it was 43.1 (0.024). Postoperatively in the plating group there were 13 complications and in the interlocking group there were 6 cases with complications (p=0.009). Conclusion: Cases where both plating and interlocking nailing can be done, plating should be preferred as plating offers better result with respect to pain and function of the shoulder joint.

Effect of minimally invasive plate osteosynthesis through two approaches on bone metabolic activity and radial nerve injury in patients with humeral midshaft fracture

To compare application of minimally invasive plate osteosynthesis (MIPO) through two approaches for patients with humeral midshaft fracture, and analyzes the effect on bone metabolic activity and radial nerve injury. From April 2014 to May 2017, 76 patients with humeral midshaft fracture treated by MIPO were selected and randomly divided into group A (anterior approache group) and group B (lateral approach group) according to random number stable. In group A, there were 38 patients including 22 males and 16 females, aged from 18 to 74 years old with an average age of(48.21±5.79) years old; 24 patients were caused by traffic accidents, 6 patients were caused by heavy object crushing, 8 patients were caused by falling down; 20 patient were on the right side, 18 patients were on the left side; 15 patients were type A, 17 patients were type B, 6 patients were type C according to AO classification; the patients were treated by MIPO through anterior approach. In group B, there were 38 patients including 23 males and 15 females, aged from 20 to 73 years old with an average age of(48.40±5.81) years old; 26 patients were caused by traffic accidents, 5 patients were caused by heavy object crushing, 7 patients were caused by falling down; 17 patients were on the right side, 21 patients were on the left side; 15 patients were type A, 18 cases were type B, 5 cases were type C according to AO classification; the patients were treated by MIPO through lateral approach. Intraoperative blood loss, operative time, hospital stays, fracture healing time between two groups were compared. Bone gla protein (BGP), collagen C-terminal peptide (CTX) and osteoprotegerin (OPG) were tested before and after operation. The incidence of radial nerve injury after operation was observed. All patients were followed-up from 12 to 18 months with an average of (15.4±2.1) months. There were no statistical differences in operative time, intraoperative blood loss between two groups. Hospital stays, fracture healing time in group A were(6.52±1.81) d, (13.27±3.01) weeks respectively, while in group B were(9.61±1.99) d, (14.83±3.08) weeks; and had differences between two groups. There were no differences in BGP, OPG and CTX, BGP between two groups and OPG in group A at 1 month after operation were(7.10±0.58) ng/ml, (173.67±9.12) pg/ml and higher than that of group B(6.63±0.62) ng/ml, (152.80±9.23) pg/ml; while CTX in group A (224.52±12.67) μg/ml was lower than that of group B(259.13±13.54) μg/ml(P<0.05). No patient occurred radial nerve injury in group A, 4 patients occurred radial nerve injury in group B, and had statistical differences between two groups(χ²=4.220, P<0.05). Compared with lateral approach, anterior approach has much more effective in minimally invasive MIPO for humeral shaft fractures, which could improve bone metabolism and reduce risk of radial nerve injury.

Open reduction and internal fixation of humeral midshaft fractures: anterior versus posterior plate fixation

BackgroundFractures of the humeral shaft represent 2–4% of all fractures. Fractures of the humerus have traditionally been approached posteriorly for open reduction and internal fixation. Reports of treating midshaft fractures with an open anterolateral approach and anterior plating are limited. The purpose of this study was to evaluate a series of humeral shaft fractures treated with plate osteosynthesis regarding the effect of the approach and plate location on the healing rate and occurrence of complications.MethodsWe conducted a retrospective chart review of patients aged over 18 years with humeral midshaft fractures treated with anterior or posterior plate fixation. Selection of the approach to the humerus was based on the particular pattern of injury and soft tissue involvement. The minimum follow-up duration was set at six months. The outcomes included the rate of union, primary nerve palsy recovery, secondary nerve damage, infection and revision surgery.ResultsBetween 2006 and 2014, 58 patients (mean age, 59.9; range, 19–97 years) with humeral midshaft fractures were treated with anterior (n = 33) or posterior (n = 25) plate fixation. After a mean follow-up duration of 34 months, 57 of 58 fractures achieved union after index procedure. Twelve fractures were associated with primary radial nerve palsy. Ten of the twelve patients with primary radial palsy recovered completely within six months after the index surgery. In total, one patient developed secondary palsy after anterior plating, and three patients developed secondary palsy after posterior plating. No significant difference in the healing rate (p = 0.4), primary nerve palsy recovery rate (p = 0.6) or prevalence of secondary nerve palsy (p = 0.4) was found between the two clinical groups. No cases of infection after plate fixation were documented.ConclusionsOpen reduction and internal fixation using an anterior approach with plate fixation provides a safe alternative to posterior plating in the treatment of humeral shaft fractures. An anterior approach allows supine positioning of the patient and yields union and complication rates comparable to those of a posterior approach with plate fixation for the treatment of humeral shaft fractures.

The Influence of Leaping Frequency on Secondary Bone in Cercopithecid Primates

Bone remodeling is at least partially mediated by the mechanical environment created by an animal's behavior. Here, we test the hypothesis that bone remodeling is primarily induced by high magnitude loads, likely encountered during leaping/bounding behaviors. Osteon population density (OPD), osteon cross-sectional area (On.Ar), and relative osteonal area (%HAV) were measured from femoral and humeral midshaft thin sections of four cercopithecids (N = 5 per species) from Taï Forest, Côte d'Ivoire: Colobus polykomos, Piliocolobus badius, Cercopithecus diana, and Cercocebus atys. All species are generalized quadrupeds but vary in leaping frequency and overall activity budget. Differences between taxa with high (C. polykomos and P. badius) and low leaping frequency (C. diana and C. atys) were assessed via a phylogenetically informed generalized linear mixed model using Markov Chain Monte Carlo methods. Femoral OPD and %HAV are greater in the high frequency leapers than in low frequency leapers, suggesting that frequent high magnitude loads engender remodeling, however, there is no similar pattern in the humerus, which presumably also experiences high magnitude loads during leaping. Additionally, OPD and %HAV are greater in the humerus than the femur, despite load magnitude being presumably higher in the femur. These results provide conflicting support for hypotheses about load magnitude and load frequency as they relate to bone remodeling activity. Future work is proposed to parse out the respective effects of load magnitude and frequency on bone remodeling. Anat Rec, 302:1116-1126, 2019. © 2018 Wiley Periodicals, Inc.

A large temnospondyl humerus from the Rhaetian (Late Triassic) of Bonenburg (Westphalia, Germany) and its implications for temnospondyl extinction

Temnospondyls are a group of basal tetrapods that existed from the Early Carboniferous to the Early Cretaceous. They were characteristic members of Permian and Triassic continental faunas around the globe. Only one clade, the Brachyopoidea (Brachyopidae and Chigutisauridae), is found as relics in the Jurassic of eastern Asia and the Cretaceous of Australia. The other Late Triassic clades, such as Plagiosauridae, Metoposauridae, and Cyclotsauridae, are generally believed to have gone extinct gradually before the end of the Triassic and putative Rhaetian records are stratigraphically poorly constrained. Temnospondyl humeri all show a similar morphological pattern, being stout, short, with widened ends, and with a typical torsion between the proximal and distal heads. Based on these characters, a humerus found in a Rhaetic-type bonebed in unequivocally Rhaetian sediments (marine Exter Formation) in a clay pit at Bonenburg (eastern Westphalia, Germany) was identified as pertaining to the temnospondyl cf. Cyclotosaurus sp. The humeral midshaft histology also supports temnospondyl affinities and serves to exclude plesiosaurs and ichthyosaurs from consideration. This find is the geologically youngest record of a non-brachyopoid temnospondyl, indicating that cyclotosaurids survived well into the Rhaetian, likely falling victim to the end-Triassic extinction.

Morphology and structure of Homo erectus humeri from Zhoukoudian, Locality 1.

BackgroundRegional diversity in the morphology of the H. erectus postcranium is not broadly documented, in part, because of the paucity of Asian sites preserving postcranial fossils. Yet, such an understanding of the initial hominin taxon to spread throughout multiple regions of the world is fundamental to documenting the adaptive responses to selective forces operating during this period of human evolution.MethodsThe current study reports the first humeral rigidity and strength properties of East Asian H. erectus and places its diaphyseal robusticity into broader regional and temporal contexts. We estimate true cross-sectional properties of Zhoukoudian Humerus II and quantify new diaphyseal properties of Humerus III using high resolution computed tomography. Comparative data for African H. erectus and Eurasian Late Pleistocene H. sapiens were assembled, and new data were generated from two modern Chinese populations.ResultsDifferences between East Asian and African H. erectus were inconsistently expressed in humeral cortical thickness. In contrast, East Asian H. erectus appears to exhibit greater humeral robusticity compared to African H. erectus when standardizing diaphyseal properties by the product of estimated body mass and humeral length. East Asian H. erectus humeri typically differed less in standardized properties from those of side-matched Late Pleistocene hominins (e.g., Neanderthals and more recent Upper Paleolithic modern humans) than did African H. erectus, and often fell in the lower range of Late Pleistocene humeral rigidity or strength properties.DiscussionQuantitative comparisons indicate that regional variability in humeral midshaft robusticity may characterize H. erectus to a greater extent than presently recognized. This may suggest a temporal difference within H. erectus, or possibly different ecogeographical trends and/or upper limb loading patterns across the taxon. Both discovery and analysis of more adult H. erectus humeri are critical to further evaluating and potentially distinguishing between these possibilities.

Investigation of Kryptonite™ bone cement in hybrid screw configurations of locking plate humeral midshaft fixation: A study of surrogate bone model

PurposeLocking compression plates (LCP) allow trauma and orthopedic surgeons to have a variety of options for utilizing locking and non-locking screw features. In this study, the hybrid constructs of mixed unicortical and bicortical screws were investigated for humerus midshaft fractures. The locking and non-locking features were also incorporated into the hybrid LCP constructs. Kryptonite™ bone cement is biocompatible with low exothermic properties and strong metal adhesion. This novel bone cement was incorporated into the non-locking screw feature to compare its mechanical effect with that of a traditional locking screw feature. MethodsA total of 24 synthetic bones (Sawbones® Inc., USA) were equally divided into three groups (n=8). The control group obtained traditional LCP fixation (JSM Medimax Inc., India) with bicortical screws, while the hybrid locking constructs employed a mix of bicortical and unicortical screws. The two bicortical screws in hybrid constructs were placed at the end holes of the LCP constructs and the unicortical screws were placed into the remaining holes. The hybrid locking (HL) group contained locking unicortical screws, whereas the hybrid non-locking group (HNK) utilized non-locking screw features incorporating the Kryptonite™ bone cement in the plate/screw bone construct. Specimens were tested by dynamic and static analysis. The eight total constructs were equally divided into two subgroups (n=4) to conduct axial compression and torsion test individually. The low cyclic test was conducted for dynamic analysis, which included 10,000 cycles at 1Hz frequency with a cyclic loading of 0–500N of axial force for the axial compression test and 0–20° of angular displacement for the torsion test. The static analysis was run by a failure test with a nondestructive strain rate of 0.1mm/s for the axial compression test and 0.5°s−1 for the torsional test. The construct stiffness of axial compression and torsion were derived from the linear portion of the load-displacement curves. The yield strength of axial compression and torsion was determined by using offset methods. The results of stiffness and yield strength were compared by using both one-way ANOVA and Scheffe and Games-Howell post hoc tests to analyze statically significant differences among the three groups. ResultsSpecimens completed 10,000 cycles in the dynamic analysis of axial and torsional cyclic tests without major deformation. To compare with the control group in static analysis, the HL and HNK groups achieved positive effect in axial stiffness, 12.3% and 10.5% greater than the control group respectively. HL obtained axial yield strength about 12% less than the control group. The HNK group was equivalent with the control group in axial yield strength. The torsional stiffness and yield strength were found similar in three groups, which indicated torsional equivalence among them. The stiffness and yield strength from axial compression and torsion were found statically non-significant among three groups. ConclusionsHybrid LCP constructs were initially showed to maintain equivalent axial and torsional stability with the traditional method. Kryptonite™ hosted mechanical and biological advantages for internal plate/screws (PLT) fixation.

Phenotypic plasticity and constraint along the upper and lower limb diaphyses of Homo sapiens.

Morphological variation along the human limb reflects complex structural trade-offs between bone strength and mass. Here we assess how varying levels of plasticity and constraint affect this structure and influence the response to habitual loading along the diaphysis. Cross-sectional geometric properties including total area, cortical area, and rigidity were compared from the upper (humerus: 50% of length, radius: 66%, 50%, 4%) and lower (tibia: 50%, 38%, 4%) limbs of male varsity-level athletes and matched controls with distinct habitual loading histories. Geometric properties among cricketers and swimmers were significantly greater at the humeral midshaft, mid-proximal radius, and radial midshaft compared to controls. By contrast, no significant differences were found among athletes or controls at the distal radius. The tibial midshafts of hockey players and runners also displayed greater area and rigidity compared to controls. Differences in geometry among the three groups became less pronounced distally, where structure was comparable among athletes and controls at 4% of tibial length. Additionally, coefficients of variation revealed that variation among athletes of the same sport was highest distally in both the upper and lower limb and lowest at midshaft, where structure most closely reflected the activity pattern of each loading group. These results support previous research suggesting that distal limb sections are more tightly constrained by safety factors compared to midshafts and proximal sections. Overall, it appears that plasticity and constraint vary not only between limb segments in correspondence to known activity patterns, but also along specific sections of the diaphysis.

Estimating the Body Weight of Byzantine Dogs from the Theodosius Harbour at Yenikapı, Istanbul

In the present study, humeral and femoral midshaft circumferences were used in the weight estimation of dogs from the ancient site of the Theodosius Harbor in Istanbul. According to the calculations taken on each humerus and femur, body weight distribution of the Byzantine dogs from the Theodosius harbour was observed to be 7.953-22.385 kg. The relative ease to accommodate Terrier-size dogs in urban environments may have led to a preference for such breeds in Constantinople. It is possible that these ‘lightand medium-sized mesocephalic dogs’ were also used as ‘alarm’ guards in Constantinople. We suggest that the presence of several bones in the Yenikapi excavation area may indicate that dogs were simply buried or dumped as rubbish after death in everyday life in Constantinople.

Radioulnar space available at the level of the biceps tuberosity for repaired biceps tendon: a comparison of 4 techniques

It is unknown whether certain methods of distal biceps tendon repair lead to an increased propensity of impingement of the repaired tendon. The purpose of this study was to evaluate various repair techniques in a cadaveric model to determine the radioulnar space available for the repaired biceps tendons. Nine matched pairs of quartered, fresh-frozen cadaveric arms were transected at the level of the humeral mid shaft and the distal radiocarpal joint. Distance measurements and the angular relation of the bicipital tuberosity were measured at 5 forearm pronation-supination positions. These measurements were taken under each of the following conditions: intact native biceps, resected native tendon, suture anchor fixation of the biceps, suspensory suture device fixation of the biceps, tendon repair using a tenodesis technique, and fixation of the tendon using a trough technique. There were no significant differences in radioulnar space available after biceps tendon repair with the forearm in a supinated position. However, when the forearm was in a neutral or pronated position, the suture anchor method consistently had the lowest biceps insertion-to-ulna distance (0.6 to 2.1 cm). All forearm positions, except full supination, showed significant differences in terms of radioulnar space available for the repaired biceps. This study shows that the space available for the biceps tendon decreases with forearm pronation after reconstruction for all repair techniques. It appears that using suture anchors to repair the biceps tendon may predispose the repaired tendon to impingement when compared with other fixation techniques.

Outcomes following operative and non-operative management of humeral midshaft fractures: a prospective, observational cohort study of 47 patients

BackgroundAlthough the non-operative management of closed humeral midshaft fractures has been advocated for years, the increasing popularity of operative intervention has left the optimal treatment choice unclear.ObjectiveTo compare the outcomes of operative and non-operative treatment of traumatic closed humeral midshaft fractures in adult patients.MethodsA multicentre prospective comparative cohort study across 20 centres was conducted. Patients with AO type 12 A2, A3 and B2 fractures were treated with a functional brace or a retrograde-inserted unreamed humeral nail. Follow-up measurements were taken at 6, 12 and 52 weeks after the injury. The primary outcome was fracture healing after 1 year. Secondary outcomes included sub-items of the Constant score, general patient satisfaction, complications and cost-effectiveness parameters. Functions of the uninjured extremity were used as reference parameters. Intention-to-treat analysis was applied with the use of t-tests, Fisher’s exact tests, Mann–Whitney U-tests and adjusted analysis of variance (ANOVA).ResultsForty-seven patients were included. The patient sample consisted of 23 women and 24 men, with a mean age of 52.7 years (range 17–86 years). Of the 47 cases, 14 were treated non-operatively and 33 operatively. The follow-up rate at 1 year was 81%. After 1 year, 11 fractures (100%) healed in the non-operative group and at least 24 fractures (≥89%) healed in the operative group [1 non-union patient (4%) and no data for 2 patients (7%)]. There were no significant differences in pain, range of motion (ROM) of the shoulder and elbow, and return to work after 6 weeks, 12 weeks and 1 year. Although operatively treated patients showed significantly greater shoulder abduction strength (p = 0.036), elbow flexion strength (p = 0.021), functional hand positioning (p = 0.008) and return to recreational activities (p = 0.043) after 6 weeks, no statistically significant differences existed in any outcome measure at the 1-year follow-up.ConclusionsOur findings indicate that the non-operative management of humeral midshaft fractures can be expected to have similar functional outcomes and patient satisfaction at 1 year, despite an early benefit to operative treatment. If no radiological evidence of fracture healing exists in non-operatively treated patients during early follow-up, a switch to surgical treatment results in good functional outcomes and patient satisfaction.

Pin Size Influences Sagittal Alignment in Percutaneously Pinned Pediatric Supracondylar Humerus Fractures

No study examining pin constructs has adequately addressed pin size and its role in fracture fixation. Our goal was to review our experience with Wilkins-modified Gartland type-III pediatric supracondylar humerus fractures treated with closed reduction and percutaneous pinning to evaluate the effects of pin size within 2 different pin constructs on maintenance of reduction and on the risk of surgical complications. We retrospectively reviewed the medical records of pediatric patients with Wilkins-modified Gartland type-III supracondylar humerus fractures that were closed reduced and percutaneously pinned at our institution from March 1999 through December 2008. We grouped those 159 patients by fracture stabilization method (lateral-entry-pin or crossed-pin constructs), by pin size ratio (ie, ratio of pin diameter to the humeral midshaft cortical thickness: small ≤0.9; large >0.9), and then by 4 combinations of pin construct and pin size ratio. For each group, we evaluated radiographs for immediate postoperative reduction (coronal and sagittal alignment), maintenance of reduction at last follow-up, and the number of surgical complications. We used the Student t test, χ² test, Mann-Whitney U test, and Wilcoxon Signed Rank test to examine for significance, which was set at P<0.05. Although we found no significant differences between the groups immediately after surgery, final follow-up sagittal alignment was significantly more likely to be maintained in the large pin size ratio group than in the small pin size ratio group. For 2 types of surgical complications, infection and nerve palsy, we found no statistically significant differences in these complications between the pin construct or pin size ratio groups. Large pin sizes improved radiographic sagittal alignment at final follow-up without an increased rate of infection or ulnar nerve palsy. Level III Therapeutic Study.

CP3 Progressive ataxia with unusual radiographic findings

A 72-year-old woman presented with a 2-year history of slowly progressive ataxia, accompanied by 13 kg weight loss. MRI imaging of the brain revealed T2-weighted hyperintensities in the pons, midbrain...