Complex injuries of upper extremity are among the most challenging cases for the treating physician, especially when comminuted fractures, neurovascular injuries or extensive soft tissue loss are accompanied with. Reconstruction of the skeleton is usually very difficult since plates, screws, or external fixation do not always provide sufficient stability. Recently, flexible titanium intramedullary nails that initially developed for pediatric trauma, were introduced in treatment of open and complex injuries of upper extremity.

From 1995 – 2001 20 patients (16 male, 4 female) with a mean age 28 years (15–60 years) were managed at our department with flexible titanium intramedullary nailing. 12 sustained forearm fractures, humeral ones, as well as 4 concomitant fractures of forearm and humerus.Nailing was performed either closed with image intensifier or open through the wound with minimal stripping. Postoperatively a splint was applied. Rehabilitation regime was adjusted to soft tissue care; when severe soft tissue wasn’t encountered, early mobilization of the arm was applied.

Union rate was conceivably high, in a relative short time. In 3 cases of segmental fractures of radius, nail removal and subsequent fixation with plate and screws due to nonunion of distal site, was necessitated.

Operative technique is simple, fast and reliable providing satisfactory reduction, stable fixation with minimal further tissue trauma and mostly early mobilization

Over the last decade 18 patients with thoracic outlet syndrome (T.O.S.) were treated at our department by scalenectomy through transverse supraclavicular approach.Preoperatively all of the patients had experienced pain, paresthesias and tingling of neck and shoulder with radiation to the ipsilateral arm, whereas 8 of them had additionally vascular symptoms.

Postoperatively (6 months – 2 years) 12 patients were still suffering or they had a deterioration of symptoms. 9 were male (80%) whereas 3 were female (20%).

Resection of the first rib through transaxillary approach was performed and six months later they all had returned back to work, reporting complete relief (80%) or significant improvement (20%).After 4 years of follow up there were no recurrences.

In one case there was a long thoracic nerve palsy that spontaneously recovered after 6 months.

Whilst the cause of recurrence remains controversial, many authors suggest that this is due to adhesions of scar tissue to the nerves and vessels at the axilla. Therefore, intervention should be planned and performed by an experienced surgeon, avoiding complications and minimizing tissue trauma.

In conclusion, prevention is the best way of managing recurrences; accurate clinical evaluation, careful preoperative planning and meticulous dissection are the cornerstones of a successful outcome.

Thoracic outlet syndrome (TOS) is characterized by a series of symptoms, which arise from the compression of the neurovascular bundle between the supraclavicular space and its entry to the axilla. The type and intensity of symptoms is relative to the site of compression and the anatomic structures involved.

Between 1990 and 2001, 42 patients were operated for thoracic outlet syndrome utilizing a supra-clavicular incicion (8 bilateral). 12 were male and 30 female. Ages ranged from 21 to 55 years (mean 31). The time interval between the onset of first symptoms and operation was 7 to 12 months in 16 patients and 1 to 4 years in 26 patients. All patients had neurologic symptoms with pain, paresthesias and numbness in the lateral neck, shoulder or arm. The duration and intensity of symptoms was variable. 12 of them had symptoms arising from the arterial compression. Preoperative evaluation included a formal clinical and neurologic examination, radiographs of the chest and cervical spine, Electromyography was often performed if a carpal tunnel syndrome was suspected. Angiography was performed in patients with vascular symptoms. MRI scan of the cervical spine and supraclavicular spaces were routine practice. Most of the patients had undergone prolonged conservative treatment including medication (muscle relaxants and analgesics), physiotherapy, exercises and cervical brace immobilization. This approach produced only temporary improvement or even aggravation of their neurologic complaints.

Intraoperativelly we found: Hypertrophy of the scalene muscle with aberrant or broad insertion on the first rib (31 pts), perineural fibrosis (5 pts), long type cervical rib (2 pts), fibromuscular bands between the 7 transverse process and the first rib (4 pts), vascular bridge pinching the lower trunk (4 pts). In four cases no obvious anatomic finding within the thoracic outlet affecting the brachial plexus could be found. The follow up period ranged from 6 months to 10 years (mean 6 years). Results were classified as excellent in 16, who were free of symptoms. Good in 12, who complained of mild symptoms on daily activities but were significantly improved. Poor in 6 who had persistent or aggravation of their symptoms. 4 patients from the poor results group were treated by 1st rib excision, on a later stage and experienced significant improvement.

The operative complications include one case of pneumothorax and a temporary dysfunction of the phrenic and XI cranial (accessory) nerve. No postoperative complications were found and the average hospitalization period ranged between 24 – 48 hours.

Humeral shaft fractures are among the most frequent fractures encountered in Orthopaedic Traumatology. Their treatment can be either conservative or operative depending on the location (proximal, middle or distal third), type (spiral, oblique, or transverse), radial nerve involvement, concomitant presence of thoracic injuries that preclude general anesthesia, as well as surgeon’s experience. Non union or delayed union complicates some of the conservatively and very few of the operatively treated fractures.

We report of our experience with the management of humeral shaft non unions in 28 patients treated at our institution from 1990 to 2000. Six were male and twelve female aging from 21 to 68 years (mean 45 years).The interval between initial injury and operation varied from 6 months to 3 years (average 10 months).Regarding the location of non union,20 cases were located in the middle, 6 cases in the upper and 2 cases in the distal third.

Operative technique: under general anesthesia using anterolateral approach for middle and distal third and deltopectoral approach for proximal third , the site of pseudarthrosis was exposed. In transverse and slightly oblique fractures a self compression plate was implanted without resection of pseudarthrosis or excessive soft tissue detachment .In spiral and true oblique fractures reduction performed initially, maintained with k-wires and fixated with self compression plate. Upon completion of osteosynthesis suction drain was put ,followed by wound closure and elastic bandage.

Postoperatively a colar cuff was used for 2 weeks .Follow up examination with radiographic evaluation was done after 3 and 6 months.

Signs of incomplete callus formation were obtained after 3 months whereas solid union was achieved after 6 months in all patients without any serious complication.