Aims. Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this. Methods. Included RCTs were ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation), a two-arm study of surgery versus non-surgical treatment for proximal humerus fractures, and UK FROST (United Kingdom Frozen Shoulder Trial), a three-arm study of two surgical and one non-surgical treatment for frozen shoulder. To determine whether early treatment effects were present, the primary outcome of Oxford Shoulder Score (OSS) was compared on forest plots for: the chief investigator’s (CI) site to the remaining sites, the first five sites opened to the other sites, and patients grouped in quintiles by randomization date. Potential for bias was assessed by comparing mean age and proportion of patients with indicators of poor outcome between included and excluded/non-consenting participants. Results. No bias in treatment effect was observed overall for the CI site, or the first five sites, compared with the remaining sites in either trial. An early treatment effect on the OSS was observed for the first quintile of participants recruited to ProFHER only (clinically relevant difference of seven points). Selection bias for age was observed in the ProFHER trial only, with slightly younger patients being recruited into the study. Both trials showed some selection bias for markers of poor prognosis, although these did not appear to change over time. Conclusion. No bias in treatment effects overall were found at the CI or early sites set-up. An early treatment effect was found in one of the two trials, which was likely a chance effect as this did not continue during the study. Selection bias was observed in both RCTs, however this was minimal and did not impact on outcome. Cite this article: Bone Jt Open 2023;4(2):96–103

Purpose of the study: To analyse the ability of Blount’s technique (closed reduction and immobilisation with a collar and cuff sling) for the treatment of completely displaced extension-type (Gartland III) supracondylar fracture of the humerus in children. Introduction: Blount’s technique is usually considered to be unreliable for completely displaced extension-type supracondylar fracture of the humerus. According to the literature, it increases the risks of secondary displacement and neurovascular complications. Consequently, many authors prefer traction or internal fixation with K-wires. Nevertheless, some authors stated that Blount’s technique can be efficient in selected cases of type-III fractures. As we usually used Blount’s technique in our Institution even in cases of type-III fractures we decided to analyse our results. Material and method: we evaluated retrospectively 46 consecutive cases of completely displaced supracondylar fractures of the humerus treated in our Institution. Mean age was 7 years (3–11). There were 31 left side and 15 right side, 35 males and 11 females. 7 patients who had associated fracture of the forearm or neurovascular damage were treated surgically and stabilised with pins. In 39 patients where the fracture was isolated without initial neurovascular complication, closed reduction under general anesthesia and stabilization with a collar according to Blount’s technique was first attempted. Results: Among the 39 patients where Blount’s technique was used, external reduction failed in 8 cases (in 5 cases, the reduction was not satisfactory, and in 3 cases, the reduction was unstable). These 8 patients were operated during the same anesthesia. Reduction and stabilisation was achieved by open reduction and pinning. Among the remaining 31 patients where closed reduction and external stabilisation could be achieved, we did not note any neurovascular complication or compartment syndrome. 8 days postoperatively, secondary displacement was noted in 2 patients. These 2 patients had operative treatment. The 29 remaining patients were reviewed with a mean follow-up of 29 months (2–6 years). Consolidation was obtained between 30 and 45 days in all cases. At the final follow-up, according to Flynn’s overall modified classification, the clinical result was considered to be excellent in 26 patients and good in 3 patients where a 10° limitation of flexion was noted. The carrying angle was identical to the controlateral side in all cases. Radiographic assessment using Baumann angle was normal in all 29 cases (65° to 75°). Conclusion: Blount’s technique can be used in selected cases of completely displaced extension-type supracondylar fractures of the humerus in children. It appears to be safe and reliable if a perfect and stable initial reduction can be obtained

The purpose of this study is to introduce our treatment by skeletal traction in brace and to report the safety and easiness of this method and low incidence of cubitus varus. In 1980 we developed a specially designed brace for treating the supracondylar fracture, along with a technique of spontaneous reduction by skeletal traction to develop an easy and safe treatment. The brace is made of plastics and aluminum alloy that are radiolucent. The humeral slide bar with attached axillary pad can be moved up and down to adjust the height of the upper arm for each patient. From 1980 to 1999 we have treated 190 children with displaced supracondylar fracture of the humerus. Their ages ranged from 2 to 14 years old and average of age was 7 years old. The fractures occurred most frequently between the ages of 5 to 6. More boys than girls were injured and the left elbow were more often than the right. Among 190 cases, severely displaced cases were most common. (64%) and moderate case 20%, mild case 16%. The period of follow up was 6 months to 11 years, mean 4 years. Placing the arm in the brace with the elbow flexed at right angle, unstable fracture site will be stabilized first. Skeletal traction is performed by a spring through the winged screw. The traction is maintained for three to four weeks. Spontaneous reduction of the displaced fragment can be expected and we emphasize that any manipulative technique is not performed during the treatment at all. Among 190 patients, cubitus varus occurred in only 3 (1.6%) cases because of technical failure. All patients except one obtained excellent functional results, one had 25 degrees of limitation of the elbow flexion. There were no vascular problems or Volkmann’s contracture and ectopic ossification. The results were satisfactory. Our treatment utilizing the brace and skeletal traction for supracondylar fracture of the humerus in children is safe and effective in preventing cubitus varus

Supracondylar fractures of the humerus (SCH) are one of the most common orthopaedic injuries in childhood. Numerous studies worldwide demonstrate that play equipment is a common mechanism of injury for SCH. Our study aimed to identify the prevalence of play equipment related SCH in a large population in Western Sydney. We conducted a retrospective analysis of 856 infants who suffered a SCH between 2001–2007 and were treated at The Children's Hospital at Westmead. We obtained data on patient demographics, mechanism of injury, severity of SCH (Gartland classification), and management of SCH (open reduction vs closed reduction vs. non operative management). Of the total 856 patients, 739 provided useful information for analysis. In 696 of these patients the mechanism of injury could be determined according to the patients information provided in the medical record. The mechanisms of injury were as follows: trampoline 72 (10.3%), monkey bars 58 (8.3%), slides 26 (3.7%), other playground equipment 84 (12.0%), home furniture 157 (22.6%), bikes 39 (5.6%), non-equipment related fall 260 (37.3%). Of the patient demographics, there was a significant correlation between the age groups (0–3, 4–7, 8+ years) and severity of SCH (Ï24 = 18.36, p=0.001). Fifty-two percent of Gartland type three fractures occurred in the age group of 4–7 years. The study demonstrates that playground equipment represents a major mechanism of injury of SCH in children. In particular trampoline related SCH and to a lesser degree monkey bar related SCH, represent an area in which primary preventative strategies should be targeted

Fractures of humeral shaft are commonly seen in orthopaedic practice accounting for approximately 3% of all fractures. Treatment of these injuries continue to evolve as advances are made in both nonoperative and operative management. We performed a prospective study in the management of fractures of diaphysis of humerus by interlocking nail fixation and dynamic compression plating (DCP) was undertaken over a period of 3 years. Forty five patients with humerus fracture were treated with either interlocking nailing or plating. Rodriguez-Merchan et al criteria was used to compare results of both groups postoperatively. Fractures with unacceptable alignment was the most common indication for operative intervention (53%). While only 50% of the interlocking group had healed by 16 weeks, 75% of the plating group had united by this time. Overall results (Rodriguez-Merchan) show 65% excellent and good results in interlocking group and 93% similar results in the plating group. Postoperative radial nerve palsy was not seen in the interlocking group but was noted in 6.25% of the plating group. All of them recovered uneventfully with time. Plating is generally considered gold standard and to have predictable results in treatment of humerus shaft fractures. We have noted earlier union and better overall results in the plating group. Interlocking nailing is particularly preferable in communited, segmental and pathological fractures

Objectives. The goal of this study is to investigate the relation between indicators of osteoporosis (i.e., bone mineral density (BMD), and Cortical Index (CI)) and the complexity of a fracture of the proximal humerus as a result of a low-energy trauma. Methods. A retrospective chart review of 168 patients (mean age 67.2 years, range 51 to 88.7) with a fracture of the proximal humerus between 2007 and 2011, whose BMD was assessed at the Fracture Liaison Service with Dual Energy X-ray Absorptiometry (DXA) measurements of the hip, femoral neck (FN) and/or lumbar spine (LS), and whose CI and complexity of fracture were assessed on plain anteroposterior radiographs of the proximal humerus. Results. No significant differences were found between simple and complex fractures of the proximal humerus in the BMD of the hip, FN or LS (all p > 0.3) or in the CI (p = 0.14). Only the body mass index was significantly higher in patients with a complex fracture compared with those with a simple fracture (26.9 vs 25.2; p = 0.05). Conclusion. There was no difference in BMD of the hip, FN, LS or CI of the proximal humerus in simple compared with complex fractures of the proximal humerus after a low-energy trauma. Factors other than the BMD and CI, for example body mass index, may play a more important role in the complexity of this fracture. Cite this article: J.W.A.M. den Teuling, B.S. Pauwels, L. Janssen, C.E. Wyers, H. M. J. Janzing, J.P.W. van den Bergh, J. W. Morrenhof. The Influence of bone mineral density and cortical index on the complexity of fractures of the proximal humerus. Bone Joint Res 2017;6:584–589. DOI: 10.1302/2046-3758.610.BJR-2017-0080

Aim. To investigate the effectiveness of a decision-based protocol designed to minimise the use of medial incisions when performing crossed-wire fixation of supracondylar fractures of the distal humerus whilst minimising ulnar nerve injury. Method. We have employed a protocol for placing the medial wire during crossed k-wire fixation of supracondylar fractures dependent upon the medial epicondyle. When this is palpable, the wire is introduced percutaneously; when it is not, a mini-incision is made. All cases of closed reduction and crossed K-wiring of supracondylar fracture over a three year period (2008–2011) were identified from our department database. Cases with a neurological injury identified pre-operatively, and those in which the protocol had not been followed were excluded. Casenotes were reviewed to determine the incidence and outcomes of post-operative ulnar nerve deficit. Results. A total of 106 cases were identified, from which 36 cases were excluded, leaving 70 cases in the study. The mean age was 5 (range 1–11). 68 were extension-type injuries, of which 29 (41%) were type 2 and 39 (56%) type 3 according to the classification of Gartland. 2 were flexion-type. A mini-incision for placement of the medial K-wire was required in only 3 cases (4.3%), with percutaneous placement in all other cases. There was clinical evidence of partial ulnar nerve injury in 1 case (1.4%) which recovered spontaneously within 11 months. Conclusion. The results of this study demonstrate our protocol to be effective. Careful percutaneous placement of the medial wire can be performed in the majority of cases with little risk of significant or permanent injury to the ulnar nerve. Open placement of the medial wire is indicated in only a small proportion of cases. We suggest that the routine use of a medial mini-incision should be re-considered

Abstract. Background. Fractures Proximal humerus account for nearly 10 % of geriatric fractures. The treatment options varies. There is no consensus regarding the optimal treatment, with almost all modalities giving functionally poor outcomes. Hence literature recommends conservative management over surgical options. MULTILOC nail with its design seems to be a promising tool in treating these fractures. We hereby report our early experience in the treatment of 37 elderly patients. Objectives. To evaluate the radiological outcome with regards to union, collapse, screw back out/cut through, implant failures, Greater tuberosity migration. To evaluate the functional outcome at the end of 6 months using Constant score. Study Design & Methods. All patients aged >65 years who underwent surgery for 3,4-part fracture proximal humerus using the MULTILOC nail were included in the study after consent. Pre – existing rotator cuff disease were excluded. Within the time frame, a total of 39 patients underwent the said surgery. 2 patients were lost to follow up. All the measurements were taken at the end of 6 months and results tabulated and analysed. Results. Union was achieved in all the 37 patients. There were no varus collapse or screw backout/cut through seen in any of the patients. There was Greater tuberosity migration in 1 patient who underwent revision surgery at 6 weeks. All the patients got a minimum of 70 degrees of abduction and forward flexion. We had 29 excellent, 6 good, 2 fair and none poor results as per Constant scoring system. Study done in Tejasvini Hospital & SSIOT Mangaluru India

We retrospectively reviewed 223 cases of supracondylar fractures of elbow treated in our hospital between the years 1996 and 2000. In 30 patients we found some degree of under-reduction of the extension element of the fracture. Twenty-two of them were evaluated close to skeletal maturity. The mean age at fracture was 5.4 years and mean follow-up was 8.2 years. The radiographic remodeling, range of elbow motion and awareness of the patients of functional limitation were evaluated. At the final follow-up17 (77%) of patients have had radiographic loss of humero-condylar angle (5 or more degrees of difference compared to an uninjured side). Eleven (50%) of the patients had limited elbow flexion, and seven (31%) of them were aware of this deficit. Most of under-reductions happened when reduction was attempted in the emergency room, or when displacement was not appreciated and a cast was applied without a reduction attempt.

The conclusions are that the patients that were left to heal with some degree of extension, have had limited end-elbow flexion and may be aware of it. Although only 3 patients felt a minor functional disability at the last follow-up the 10 patients have unsatisfactory results according the Flinn’s criteria for motion restriction. The treating surgeon must be aware of this possible outcome and be more demanding in the reduction of the extension component of a fracture. Otherwise one may expect limited elbow flexion that may be clinically significant. Although the reduction of moderately displaced fractures may seem easy, it is better done in the operating room and not in the emergency room, under general anesthesia and with radiographic control.

Objectives. The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes. Methods. A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed. Results. Seven studies including 528 patients were included. The overall meta-analysis found that there was no difference in clinical outcomes. However, subgroup and sensitivity analyses found improved patient outcomes for more complex fractures managed surgically. Four-part fractures that underwent surgery had improved long-term health utility scores (mean difference, MD 95% CI 0.04 to 0.28; p = 0.007). They were also less likely to result in osteoarthritis, osteonecrosis and non/malunion (OR 7.38, 95% CI 1.97 to 27.60; p = 0.003). Another significant subgroup finding was that secondary surgery was more common for patients that underwent internal fixation compared with conservative management within the studies with predominantly three-part fractures (OR 0.15, 95% CI 0.04 to 0.63; p = 0.009). Conclusion. This meta-analysis has demonstrated that differences in the type of fracture and surgical treatment result in outcomes that are distinct from those generated from analysis of all types of fracture and surgical treatments grouped together. This has important implications for clinical decision making and should highlight the need for future trials to adopt more specific inclusion criteria. Cite this article: S. Sabharwal, N. K. Patel, D. Griffiths, T. Athanasiou, C. M. Gupte, P. Reilly. Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysisBone Joint Res 2016;5:470–480. DOI: 10.1302/2046-3758.510.2000638

Aims. The PROximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) randomised clinical trial compared the operative and non-operative treatment of adults with a displaced fracture of the proximal humerus involving the surgical neck. The aim of this study was to determine the long-term treatment effects beyond the two-year follow-up. Patients and Methods. Of the original 250 trial participants, 176 consented to extended follow-up and were sent postal questionnaires at three, four and five years after recruitment to the trial. The Oxford Shoulder Score (OSS; the primary outcome), EuroQol 5D-3L (EQ-5D-3L), and any recent shoulder operations and fracture data were collected. Statistical and economic analyses, consistent with those of the main trial were applied. Results. OSS data were available for 164, 155 and 149 participants at three, four and five years, respectively. There were no statistically or clinically significant differences between operative and non-operative treatment at each follow-up point. No participant had secondary shoulder surgery for a new complication. Analyses of EQ-5D-3L data showed no significant between-group differences in quality of life over time. Conclusion. These results confirm that the main findings of the PROFHER trial over two years are unchanged at five years. Cite this article: Bone Joint J 2017;99-B:383–92

Introduction: Supracondylar fracture of the humerus is a common upper limb fracture in children. Treatment is controversial and often technically difficult; complications are common. Cubitus varus is the most common problem with a mean incidence of 30%. A variety of methods of treatment for displaced fractures have been recommended. Materials & Method: We reviewed 20 cases of severely displaced grade III supracondylar fractures of the humerus in children. There was marked swelling and distorted local anatomy in all these cases. These fractures were managed conservatively with straight – arm lateral traction. The patients were treated in skin traction for 2 weeks. They commenced physiotherapy after that. The traction was applied with arm in 90 degrees of abduction and forearm in supination. Results: None of the patients developed any complication. All had full range of movements. None had cubitus varus deformity and none of these patients required resurgery. There was a complete patient and parent satisfaction. Discussion: Open or closed reduction with internal fixation is the most common method of treating these injuries. In some cases this can be very difficult and dangerous. The local anatomy and swelling may not permit this; hence non-operative measures have to be adopted. Conclusion: We conclude that straight – arm lateral traction is a safe and effective method of treating these fractures especially when the local anatomy is disturbed and the swelling is making operative intervention more risky and difficult. Moreover this method is also appropriate in areas where access to specialised centres in treating these injuries is either difficult or delaying

Aim

Differing reports about the surgical management of the supracondylar humeral fracture make evidence-based practice very difficult, so knowledge of the contemporary practices and opinions of an expert body can provide a useful benchmark for appraisal; the aim of this study was to obtain this information.

Purpose of the study: The reversed total shoulder prosthesis is one of the treatments currently proposed for excentered glenoid osteoarthritic degeneration with massive rotator cuff tears. In light of the mediocre or at best highly variable results obtained with osteosynthesis or humeral arthroplasty for four-fragment fractures of the proximal humerus, indications for the reversed total shoulder prosthesis have been widened to include this category of traumatology patients. The purpose of this prospective study was to report outcome with the reversed prosthesis used for complex fracture of the proximal humerus in subjects aged over 70 years. Material and methods: Ten patients, mean age 76 years, underwent surgery performed by the same surgeon to insert a Delta (DePuy) reversed prosthesis for four-fragment complex displaced fracture of the proximal humerus. The deltopectoral approach was used for all patients. The rotator cuff status was assessed intraoperatively. Clinical (Constant score) and radiological assessment were noted at 24 months. Results: During the operation, only three of the ten shoulders presented a full thickness rotator cuff tear. One patients developed a complication requiring revision: early dislocation revised with a retaining polyethylene insert without recurrent dislocation. There were no cases of glenoid loosening at last follow-up. The weighted Constant score was 65/100. A pain-free shoulder was achieved in all ten patients. Anterior elevation was 130° on average, internal rotation reached hand to buttocks and active external rotation 20°. Discussion: In patients aged over 70 years presenting a complex four-fragment fracture of the proximal humerus, the reversed prosthesis enables improved function and restoration of satisfactory joint movement. Early postoperative recovery and the gain in pain relief are encouraging factors. There was however unsatisfactory restoration of active rotation. For the elderly subject, free of a massive rotator cuff tear, rapid recovery after insertion of an reversed prosthesis should be balanced against the possible preservation of active rotations with an anatomic prosthesis

Purpose: Collapse or necrosis of the head of the humerus after fracture of the proximal humerus can be an indication for shoulder arthroplasty. The poor results classically reported have led to a search for factors predictive of the anatomic and functional outcome after arthroplasty for fracture sequelae. Material and methods: Among the 221 Aequalis prostheses implanted for the treatment of sequelae after fracture of the proximal humerus, 137 (62%) developed post-traumatic avascular osteonecrosis of the humeral head with a deformed callus of the tuberosity. Head tilt was in a valgus position in 83 shoulders and in a varus position in 54. Mean age was 61.49 years. The initial fractures were subtuberosity fractures in 20% of the cases, three-fragment fractures in 32%, and cephalobituberosity fractures with four fragments in 48% of the cases.Twenty-five percent of the patients had undergone initial osteosynthesis. The rotator cuff was repaired in 4.5%, and two osteotomies of the less tuberosity and four osteotomies of the greater tuberosity were performed at implantation. Pre- and postoperative clinical and functional outcomes were assessed with the Constant score and a function index composed of eleven usual movements. Results: Mean follow-up was 44 months (24–104), with a mean 42° gain in anterior elevation and a 29° gain in external rotation. The gain in the Constant score was +32 points (mean score 61), and +43% with the weighted score. The four subscores (pain, motion, activity, force) improved two-fold. Analysis of the eleven usual movements demonstrated recovery in 88% of the patients. The subjective satisfaction index was 86%. The mean Constant score improved significantly more after total arthroplasty (67 points) than after humerus prosthesis (55 points). Complications (per- or postoperative mechanical problem, infection, neurological disorder) or the need for revision were unfavourable elements. Discussion: Deformation and deviation of the tuberosities, especially the greater tuberosity, often leads to osteotomy during the implantation procedure. In this series, osteotomies were exceptional and functional outcomes showed that deviated tuberosities could be preserved without having an unfavourable effect on functional prognosis. Much on the contrary, the absence of a tuberosity osteotomy simplified the operative procedure and produced much better functional outcome than observed in earlier studies. The rate of complication for secondary prosthetic implantation is not negligible (15%) and a simplified procedure without osteotomy is a useful criterion. Furthermore, rehabilitation may be started earlier after implantation when it is not retarded by osteotomy bone healing, found to be an unfavourable factor. Conclusion: Implantation of a shoulder prosthesis after collapse or necrosis of the head of the humerus after proximal fracture with varus or valgus impaction has provided good functional outcome without tuberosity osteotomy since the deformation of the tuberosity is generally well tolerated

Purpose: Nonunion of the surgical neck of the humerus can occur after orthopaedic or poorly-adapted surgery after displaced subtuberosity or cephalotuberosity fracture. The purpose of this study was to report functional and radiographic outcome after treatment with shoulder prosthesis. Material and methods: Twenty-two patients who had a non-constrained shoulder prosthesis were included in this retrospective multicentric study. Mean age was 70 years and mean follow-up was 45 months (range 2 – 9 years). The initial fracture had two fragments in six patients and was a three-fragment fracture involving the head and the tubercle in thirteen and a four-fragment fracture in three. Orthopaedic treatment was given in ten cases and surgical osteosynthesis was used in twelve. Time from fracture to implant insertion was 20 months. The deltopectoral approach was used for 21 humeral implants and one total shoulder arthroplasty (glenohumeral degeneration). The tuberosities were fixed to the cemented humeral stem and a crown of bone grafts were placed around the nonunion of the surgical neck. All patients were reviewed after a minimum of two years and assessed with the Constant score and x-rays. Results: The absolute Constant score improved from 23 reoperatively to 39 postoperatively with an anterior elevation of 53° to 63°. Pain score (from 3 to 9, p = 0.001) and external rotation (from 13° to 28°, p = 0.01) were significantly improved. Forty-five percent of the patients were satisfied and 55% were dissatisfied. The type of initial treatment, type of initial fracture, and time before implantation of the prosthesis did no affect final outcome. The complication rate was 36% (eight patients), and led to five revision procedures. The radiographic work-up disclosed six cases of persistent nonunion of the greater tuberosity, two proximal migrations of the prosthesis, and one humeral loosening. Conclusion: Outcome of shoulder prosthesis for sequela after fracture of the proximal humerus with nonunion of the surgical neck is poor. No improvement in anterior elevation, force, or motion was achieved. Shoulder prosthesis for sequelae of fracture of the proximal humerus with nonunion of the surgical neck should be considered as a “limited-objective” indication only providing beneficial pain relief

Trans-articular coronal shear fractures of the distal humerus pose a significant challenge to the surgeon in obtaining an anatomical reduction and rigid fixation and thereby return of good function. A variety of approaches have been described which include the extended lateral and anterolateral approaches and arthroscopically-assisted fixation for non-comminuted fractures. Fixation methods include open or percutaneous cannulated screws and headless compression screws directed either anterior to posterior or posterior to anterior. We describe an illustrated, novel approach to this fracture which is minimally invasive but enables an anatomical reduction to be achieved. A 15 year old male presented with a Bryan and Morrey type 4 fracture as described by McKee involving the left distal humerus. He was placed in a lateral position with the elbow over a support. A posterior longitudinal incision and a 6cm triceps split from the tip of the olecranon was made. The olecranon fossa was exposed and a fenestration made with a 2.5mm drill and nibblers as in the OK (Outerbridge-Kashiwagi) procedure. A bone lever was then passed though the fenestration and used to reduce the capitellar and trochlear fracture fragments into an anatomical position with use of an image intensifier to confirm reduction. The fracture was then fixed with two headless compression screws from posterior to anterior into the capitellar and trochlear fragments (see images). Early mobilisation and rehabilitation were commenced. Follow-up clinical examination and radiographs at six weeks revealed excellent range-of-motion and function with anatomical bony union. We believe that this novel approach to this fracture reduces the amount of soft tissue dissection associated with conventional approaches and their associated risks and also enables earlier return to function with restoration of anatomy

Displaced supracondylar fracture in adults often require internal fixation. Plate fixation, requires soft tissue stripping resulting in devitalisation of bony fragments and this predisposes to risk of non union, infection and nerve injuries. This is the first report of a new technique, locked intramedullary transolecranon fossa nailing. In this technique the fracture is exposed through a limited posterior triceps splitting incision, keeping the soft tissue stripping to the minimum. The medullary canal is entered proximally through an anterior shoulder incision. A guide wire is inserted in an antegrade manner to enter the fracture site. The distal fragment is predrilled to create a tract with 3.2mm drill from proximal to distal, in such a way that the drill enters the olecranon fossa and then the proximal part of trochlea avoiding penetration of the elbow joint. The guide wire is then advanced into the tract in the distal segment. The medullary canal is reamed over the guide wire in anti-grade fashion with flexireamer. Utilising the standard antegrade technique, the nail is inserted and advanced under direct vision until tip of the nail is firmly seated in the trochlea. The proximal and distal locking are done in standard fashion. Postoperatively active mobilisation is encouraged. Four patients underwent this procedure. All the fractures healed in 3 months and at one year follow up the average arc of elbow motion is 120 degrees. There are no complications. Transolecranon fossa locked nailing is an available option to treat the displaced supracondylar fracture of humerus in adults

Introduction: To access efficacy of our protocol for treatment of displaced Gartland type 3 supracondylar fracture humerus in children by giving a small incision medially to identify correct entry point of medial wire and to save the ulnar nerve. This incision is extendable for open reduction if required and have no effect on morbidity. Methods: All Patients with displaced Gartland type 3 supracondylar fractures of humerus admitted from October 1997 to October 2003 were included into this study. They were all treated by closed or open reduction through medial approach and fixed with medial and lateral cross K-wires within 12 hours of admission. Results: There were 43 children with a mean age of 7.2 years at presentation. Follow up time averaged 48 months (range 12–84 months). No patient had iatrogenic ulnar nerve injury. The postoperative mean value of Bauman’s angle in affected elbow was 76.7° with +/− 1.0° and 74.8° with +/− 0.6° on the unaffected elbow. All patients showed satisfactory results according to Flynn’s criteria. Discussion: Cross K-wires give reliable results; a small medial incision is cosmetically more acceptable, provides an excellent view for correct entry point of the wire after visualising ulnar nerve with added advantage of extension if fracture required open reduction

Introduction: Fracture of the proximal humerus are challenging for diagnosis and treatment. The vast majority of these fracture associated with osteoporosis in elderly. Decision making for the treatment must include all arguments of fracture type, physical demands and rehabilitation cooperation of patients. This is particularly crucial in proximal humerus fracture. Results of surgery including hemiarthroplasty are difficult to predict and many times type of surgical treatment can be determined intra-operative or at least after closed manipulation attempt. Material and methods: Between September 1998 to September 2000, 68 patients underwent surgery for proximal humerus fracture. Patients who underwent hemiarthroplasty were not included in this study. Diagnosis of the fracture was based on Neer classification system and was aided by CT scan. Type of surgery was made finally after closed manipulation attempt under anesthesia. Patients were consented for closed manipulation, open reduction and internal fixation or hemiarthroplasty. Data was collected retrospectively from outpatients notes. 32 males and 36 females, age 40–88 (mean: 62), underwent closed manipulation and pinning (30), ORIF included pinning and PDS suture (32) and ORIF included PDS suture only (6). Fracture type distributed as follows: 2 parts surgical neck – 9, 2 parts GT – 6, 3 parts – 29, fracture dislocations – 6, 4 parts – 12, impacted valgus fracture 6. Four threaded pins were inserted retrograde and trimmed under the skin. Two antegrade pins were left out of the skin and banded to prevent migration to the axilla. Patients were immobilized in shoulder immobilizer for 6 weeks when pins were removed in outpatient clinic. Control X-ray was taken at 2, 4, 6, 12 weeks. If fracture was noted to be unstable, X-ray was taken every week up to 4 weeks. In case of any deterioration after 12 weeks X-ray was taken to detect signs of AVN. Rehabilitation program commenced after clinical union with passive and assisted active for 4 weeks followed by active mobilization. Follow-up ranged from 10–34 months (mean: 22) and range of motion with X-ray description were documented. Results: All fractures but one were united, fracture position was noted in 31 patients as normal in 46 (68%), head-shaft in extension in 8 (11.7%), varus head – 7 (10%), valgus head – 1 (1.4%), prominent GT – 4 (6%), prominent LT – 3 (4.4%), complete displacement – 2 (2.8%), dislocated – 1 (1.4%). Mean range of motion for all groups was: Elevation – 144 (60–180), External Rotation – 54.6 (−10–80), Internal Rotation – L1 (Throchanter – T8). Statistical analysis for fracture groups showed best results for impacted valgus and greater tuberosity fracture after open reduction and worst results were noted for 4 parts fractures and fracture dislocation. Although the study was not randomized there was no significant difference between the group of closed pinning and open surgery. Complications: Six patients had revision surgery during the early follow up due to fixation failure. In one case repinning was performed, in 2 cases closed pinning transformed to open surgery and suture of GT, in one case osteotomy and re-insertion of LT was needed, one case complete lost of fixation ended in hemiarthroplasty and one case of fracture dislocation failed to closed and open surgery and need bone block (Laterget) to prevent re-dislocation. AVN was noted in 5 cases – 2 partial and 3 complete (3% and 4.4%, respectively). Pin tract infection occurred in the 6 of prominent antegrade pins and resolved after early removal of these pins without the retrograde pins. G-H arthrosis was noted in one case after 2 years. Conclusions: Surgical treatment of proximal humerus fracture and attempt to preserve the humeral head is alternative to conservative treatment or hemiarthroplasty from the other hand. High surgical are demanded and fixation cannot be guaranteed due to minimal bone stock for fixation. Partial loss of fixation still leave better position and reasonable functional results. Further attention is needed to the lesser tuberosity which could be seen better under fluoroscopy under anesthesia