This study reviews the early results of Distal Humeral Hemiarthroplasty(DHH) for distal humeral fracture and proposed a treatment algorithm incorporating the use of this technique in the overall management of distal humeral fractures. DHH was performed on 30 patients (mean 65 years; 29-91) for unreconstructable fractures of the distal humerus or salvage of failed internal fixation. A triceps on approach was used in six and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Latitude (Tornier) in 16. Clinical review at a mean of 25 months (3–88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment. At follow up of 28 patients mean flexion deformity was 25 degrees, flexion 128 degrees, range of pronosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re- operation was required in 16 patients (53%); two revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and four ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, four had laxity and mild pain on loading (two with prosthesis or pin loosening), four had laxity associated with column fractures (two symptomatic) and 10 had asymptomatic mild laxity only. The triceps on approach had worse instability and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and seven had lucencies >1 mm; one was loose but acceptable. Five prostheses were in slight varus. Two elbows had early degenerative changes and 15 developed a medial spur on the trochlea. This is the largest reported experience of DHH. Early results of DHH show good outcomes after complex distal humeral fractures, despite a technically demanding procedure. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy. As a result of this experience anatomical and clinical pre-requisites and advise on technique are outlined. An algorithm for use of DHH in relation to total elbow arthroplasty and ORIF for the treatment of complex intra-articular distal humeral fractures with or without column fractures is proposed

Introduction. Humeral non-union may present a challenging problem. The instability from the un-united fracture leads to pain, disability and significant morbidity. The incidence of humeral shaft non-union as a complication of both operative and non-operative treatment is approximately 8% to 12%. This retrospective study reviews the results of surgical treatment of humeral fracture non-union performed by a single surgeon with a consistent surgical protocol. Material and Method. We present a retrospective analysis of a series of 51 consecutive cases of humeral fracture non-union treated in our limb reconstruction centre. Data were collected on mechanism of injury, associated co-morbidities, smoking, use of NSAIDs and treatment before referral. Patients were followed up to clinical and radiological union. Results. From 1994-2008, 48 patients with established humeral non-union were referred to our unit following initial management locally. Three patients were managed in our unit from the outset. There were 20 male and 28 female patients with a mean age of 53 years (range 15-86 years). There were 34 (68%) diaphyseal, nine (17%) proximal and eight (15%) distal humeral non-unions. The treatment in our unit involved plate fixation in 44 (86%) cases, intramedullary nailing in three (6%) and external fixation in three (6%) patients. Iliac crest bone graft, bone morphogenetic protein or a combination of these were utilised in 44 (86%) cases. Thirty-six patients required at least one surgical intervention to achieve union. Twelve patients had more than one operation. The average follow-up was 19.6 months. Union was achieved in all but one case at an average time of 9.8 months (range 3-24 months); one case developed a functionally inconsequential pseudoarthrosis. Conclusion. Union of ununited humeral fractures can be achieved consistently by providing appropriate mechanical stability and biological environment at the fracture site

Objective: The primary aim was to describe the epidemiology of the Holstein-Lewis humeral shaft fracture, its association with radial nerve palsy and the outcome regarding recovery from the radial nerve palsy and fracture healing. The secondary aim was to analyze the long-term functional outcome. Setting: Six major hospitals in Stockholm County. Design: Descriptive study. Retrospective assessment of radial nerve recovery and fracture healing. Prospective assessment of functional outcome. Patients: All 27 patients with a 12A1.3 humeral shaft fracture according to the OTA classification satisfying the criteria of a Holstein-Lewis fracture in a population of 358 consecutive patients with 361 traumatic humeral shaft fractures. Intervention: Nonoperative or operative treatment according to the decision of the attending orthopedic surgeon. Main Outcome Measurements: Recovery of the radial nerve, fracture healing and functional outcome according to the Short Musculoskeletal Function Assessment (SMFA). Results: The Holstein-Lewis humeral shaft fracture constituted 7.5% of all humeral shaft fractures and was associated with an increased risk of acute radial nerve palsy compared to other types of humeral shaft fractures, 22% versus 8% (p< 0.05). The fractures of six of the seven operatively treated patients healed after the primary surgical procedure while one fracture healed after revision surgery. The fractures of all patients treated nonoperatively healed without any further intervention. All six radial nerve palsies (two patients treated nonoperatively and four operatively) recovered. The functional outcome according to the SMFA was good with no differences between the nonoperatively and operatively treated patients: SMFA dysfunction index 7.6 and 9.7, respectively, and SMFA bother index 6.1 and 6.8, respectively. Conclusion: The Holstein-Lewis humeral shaft fracture was associated with a significantly increased risk of acute radial nerve palsy. The overall outcome regarding fracture healing, radial nerve recovery, and function is excellent regardless of the primary treatment modality, i.e. operative or nonoperative treatment. The indication for primary operative intervention in this fracture type appears to be relative

This paper reports our experience of revision open reduction, internal fixation and bone grafting of distal humeral fracture non-unions and in addition looks specifically at factors that may predispose to the development of non-union. Between 1993 and 2003 18 patients with distal humeral fracture non-unions underwent revision surgery with bone grafting and rigid internal fixation. Two patients were lost to follow-up leaving a study group of 16 patients. The patients’ age, sex, mechanism of injury, AO classification of the initial fracture and the primary treatment method were analysed with respect to possible factors predisposing to non-union. All revision procedures were performed by the senior author. The non-union site was debrided, bone grafted and rigidly internally fixed. Clinical assessment was performed using the Mayo Elbow Performance Score and radiographs were reviewed for evidence of bony union. The Mayo elbow performance scores were excellent in 11, good in 2, fair in 2 and poor in 1. Our results indicate that age, sex and mechanism of injury are not important in the development of non-union. Twelve patients (75%) however were considered to have undergone inadequate management of the original fracture. Our experience would suggest that to reduce the risk of non-union following distal humeral fractures appropriate consideration must be given to the established and well proven surgical techniques. If adequate fixation is considered beyond the experience of the treating surgeon we would strongly advise referral to a specialist unit

This study reviews the early results of elbow hemiarthroplasty for distal humeral fracture. Elbow hemiarthroplasty was performed on 30 patients (mean 65 years; 29–91) for unreconstructable fractures of the distal humerus or salvage of failed internal fixation. A ‘triceps on’ approach was used in 6 and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Lattitude (Tornier) in 16. Clinical review at a mean of 25 months (3 – 88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment. At follow up of 28 patients, mean flexion deformity was 25 degrees, flexion 128 degrees, range of pronosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re-operation was required in 16 patients (53%); 2 revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and 4 ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, 4 had laxity and pain on loading (2 with prosthesis or pin loosening), 4 had laxity associated with column fractures (2 symptomatic) and 10 had asymptomatic laxity only. The triceps on approach had worse laxity and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and 7 had lucencies > 1 mm; one was loose but acceptable. 5 prostheses were in slight varus and 2 were flexed. 2 elbows had early degenerative changes and 15 an osteophytic lip on the medial trochlea. Elbow hemiarthroplasty has good early results after complex distal humeral fractures, despite a demanding procedure, metalware removal in 40%, symptomatic laxity in 12% and column non-union in 8%. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy

Introduction. Although the majority of adult distal humeral fractures are successfully treated with ORIF, the management in frail patients, often elderly with multiple co-morbidities and osteoporotic bone, remains controversial. Elbow replacement is frequently recommended if stable internal fixation cannot be achieved, especially in low, displaced, comminuted fractures. The “bag-of-bones” method ie early movement with fragments accepted in their displaced position, is rarely considered as there has been little in the literature since 10 successful cases were reported by Brown & Morgan in 1971 (JBJS 53-B(3):425–428). We present the experience of three units in which conservative management has been actively adopted in selected cases. Methods. 44 distal humeral fractures were initially treated conservatively - 2004–2010. Mean age 73.9 yrs (40–91) and 34 F: 10 M. Clinical and radiological review at a mean follow-up of 2 years (1–6). Results. There were 18 AO Type A, 7 B and 19 C fractures. The range of elbow movement was extension/flexion 38/124, and pronation/supination 75/76 at their last follow-up. Using the Oxford elbow score (0 = worst/4 best result), the mean pain score was 2.44 (range 1–4), 2.26 (0–4) for function, and 2.04 (0–4) for psycho-social, although several patients had early dementia. Only 5 subsequently underwent replacement out of 44 patients whose residual symptoms have not been sufficient to require surgery. Discussion. We believe that there is a role for initial conservative treatment in selected higher-risk patients, as initial early mobilisation within the limits of discomfort can give good functional results. There is a significant complication rate after fixation or replacement in elderly, frail patients, which includes infection, stiffness and loosening. Unnecessary operations can be avoided in the majority of cases, with replacement of a virgin joint at a later date only if required

Since its approval by the FDA two decades ago, Negative Pressure Wound Therapy (NPWT) has become a valuable asset in the management of open fractures with significant soft tissue damage as those seen in high velocity gunshot injuries. These lesions are often associated with grossly contaminated wounds and require a prompt and effective approach. Wound dehiscence and surgical site infection are two of the most common post-operative complications, with poor results when treated with standard gauze dresses. NPTW comes as a legitimate resource promoting secondary intention healing through increased granulation and improved tissue perfusion, as well as continuous local wound drainage preventing bacterial growth and further infection. Recent evidence-based guidelines are still limited for use of NPWT in the treatment of Gustilo-Anderson type IIIB open fractures and there are few cases in literature reporting the management of upper extremity injuries. We present and discuss a successful case of a type IIIB open humeral fracture wound treated with NPWT. A 38-years-old male was admitted to the Emergency Room with a type IIIB open humeral fracture as a result of a gunshot with extensive soft tissue damage. IV antibiotic therapy was promptly started followed by surgical stabilization by intramedullary nailing with primary wound closure. The patient presented an early surgical site infection with wound dehiscence requiring secondary debridement with poor subsequent healing and deficient soft tissue coverage. After ineffective 28 days of standard gauze dresses we started NPWT. NPTW was applied using foam coverage over the dehiscence area with visible results after 13 days and complete granulation of the skin defect by the 28th day. The wound healed completely after 14 weeks of NPWT. The fracture evolved into a painless pseudarthrosis revealing an excellent functional recovery and an acceptable aesthetic result. NPTW is a valuable, effective, and well tolerated resource in the treatment of open fractures with extensive soft tissue damage such as Gustilo-Anderson type IIIB fractures. It should be considered not just as a salvage procedure but as well as a primary option especially in grossly contaminated wounds. No benefits in any form have been received from a commercial party

Purpose: Distal humeral fractures are often difficult injuries to treat. We hypothesise that more complex distal humeral fractures have unacceptable functional outcomes due to multi-factorial reasons. Methods: 42 patients with AO/ASIF type B and C fractures of the distal humerus who were treated with open reduction and internal fixation over a six year period were included in the study. All patients were from a single district general hospital. 37 (88%) were clinically, radiologically, and functionally assessed for this study, with the remainder either lost to follow-up or expired. Results: There were 21 type B and 16 type C fractures, all managed by open reduction and internal fixation. Various fixation techniques were utilised. These were performed by consultant surgeons in 14 cases and by surgeons in training in 23 cases. Average follow up was 38 months (range 22–54 months). The arc of elbow motion was 94 degrees (range 58–130), with an average extension deficit of 28 degrees (range 20–55) and an average flexion deficit of 32 degrees (range 15–45). The average arc of forearm rotation was 136 degrees (range 45–140), with an average supination of 68 (range 35–85) and an average pronation of 72 (range 45–90). The complications (n=20/37) included superficial skin infection (n=4), ulnar nerve neurapraxia (n=3), non-union of the humerus fracture (n=2), non-union of olecranon osteotomy site (n=1), intra-articular screw placement (n=1), loosened plate (n=1), loose/backed out screw (n=2), fixed flexion deformity (n=4) and mild elbow instability (n=2). Second surgery was performed in 24% (n=9/37), revision of metal work (n=2), bone grafting (n=2), anterior capsulectomy (n=4), and removal of screw (n=1). Conclusions: Fractures of the distal humerus are often more complex than appreciated, and challenging to treat, with respect to fracture union and functional outcome. A generalist practice appears adequate for achieving bony union, but inadequate for obtaining low complication rates and functional outcomes. Our data suggest that such injuries may constitute a fracture group requiring the acute intervention by centres that have specific sub-specialisation and adequate rehabilitation facilities

Aims: The purposes of this study were to design a more useful fracture classiþcation system for distal humeral fractures and to validate it by exactly reproducing methodology from a previous study. Methods: We designed a new fracture classiþcation system based upon our experience of managing these fractures. We tested its validity by reproducing methodology from a study performed in Oxford. Using the same radiographs, we asked 9 independent assessors to classify the fractures, on two separate occasions, according to the Riseborough and Radin, Jupiter and Mehne and AO classiþcation systems as well as our own Ð The Shefþeld Classiþcation. The assessors were unaware that the new system was produced for the purposes of the study. Using the Kappa statistic, the level of interobserver and intraobserver agreement was determined. Results: Amongst all observers, The Shefþeld Classiþcation is a moderately reliable (k=0.603) but substantially reproducible (k=0.713) classiþcation system. The system improves to become substantially reliable (k=0.643) amongst orthopaedic surgeons. The proportion of fractures unclassiþable by the new system is similar to the AO classiþcation (3.7%). Conclusions: By reproducing previous methodology, we have a unique study that validates The Shefþeld Classiþcation. We believe that it can be used in a management algorithm for these complex fractures

The primary aim was to assess the reliability of ultrasound in the assessment of humeral shaft fracture healing. The secondary aim was to estimate the accuracy of ultrasound assessment in predicting humeral shaft nonunion. Twelve patients (mean age 54yrs [20–81], 58% [n=7/12] female) with a non-operatively managed humeral diaphyseal fracture were prospectively recruited and underwent ultrasound scanning at six and 12wks post-injury. Scans were reviewed by seven blinded observers to evaluate the presence of sonographic callus. Intra- and inter-observer reliability were determined using the weighted kappa and intraclass correlation coefficient (ICC). Accuracy of ultrasound assessment in nonunion prediction was estimated by comparing scans for patients that united (n=10/12) with those that developed a nonunion (n=2/12). At both six and 12wks, sonographic callus was present in 11 patients (10 united, one developed a nonunion) and sonographic bridging callus (SBC) was present in seven patients (all united). Ultrasound assessment demonstrated substantial intra- (6wk kappa 0.75, 95% CI 0.47-1.03; 12wk kappa 0.75, 95% CI 0.46-1.04) and inter-observer reliability (6wk ICC 0.60, 95% CI 0.38-0.83; 12wk ICC 0.76, 95% CI 0.58-0.91). Absence of sonographic callus demonstrated a sensitivity of 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (accuracy 92%). Absence of SBC demonstrated a sensitivity of 100%, specificity 70%, PPV 40% and NPV 100% (accuracy 75%). Of three patients at risk of nonunion based on reduced radiographic callus formation (Radiographic Union Score for HUmeral fractures <8), one had SBC on 6wk ultrasound (and united) and the other two had non-bridging or absent sonographic callus (both developed a nonunion). Ultrasound assessment of humeral shaft fracture healing was reliable and predictive of nonunion, and may be a useful tool in defining the risk of nonunion among patients with reduced radiographic callus formation

Background

Humerus fracture non-union is a challenge for which a wide range of treatments exist. We present our experience of managing these by hybrid Ilizarov frame fixation, without bone graft or debridement of the non-union site.

The problem of retained drain fragments is a well known but under reported complication in the literature.

The authors present the case of a 66 years old male, who suffered a right distal humerus fracture luxation six years ago that was treated conservatively. He went to the emergency service with fever and right elbow purulent drainage.

Physical examination showed deformity, swelling and fluctuation of the right elbow with purulent drainage through cutaneous fistula. The x-ray showed instable inveterate pseudarthrosis of the distal humerus. Leucocytosis and neutrophylia with increased CRP were presente in the blood tests and the patient started empiric treatment with Ceftiaxone IV. A MRSA was isolated in cultural exam of the exsudate, and a six weeks treatment with Vancomycin IV was iniciated.

Exhaustive surgical cleaning was performed and two plastic foreing bodies (fragmented drains) were removed.

At the time of discharge the patient was afebrile, with normal analytical parameters and negative culture tests.

The orthopaedic surgeon should considerate the presence of a foreign body in patients with infected abcess and traumatic or surgery previous history.

Helical plates are preferably used for proximal humeral shaft fracture fixation and potentially avoid radial nerve irritation as compared to straight plates. Aims:(1) to investigate the safety of applying different long plate designs (straight, 45°-, 90°-helical and ALPS) in MIPO-technique to the humerus. (2) to assess and compare their distances to adjacent anatomical structures at risk. MIPO was performed in 16 human cadaveric humeri using either a straight plate (group1), a 45°-helical (group2), a 90°-helical (group3) or an ALPS (group4). Using CT-angiography, distances between brachial arteries and plates were evaluated. Following, all specimens were dissected, and distances to the axillary, radial and musculocutaneous nerve were evaluated. None of the specimens demonstrated injuries of the anatomical structures at risk after MIPO with all investigated plate designs. Closest overall distance (mm(range)) between each plate and the radial nerve was 1(1-3) in group1, 7(2-11) in group2, 14(7-25) in group3 and 6(3-8) in group4. It was significantly longer in group3 and significantly shorter in group1 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the musculocutaneous nerve was 16(8-28) in group1, 11(7-18) in group2, 3(2-4) in group3 and 6(3-8) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the brachial artery was 21(18-23) in group1, 7(6-7) in group2, 4(3-5) in group3 and 7(6-7) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.021. MIPO with 45°- and 90°-helical plates as well as ALPS is safely feasible and showed a significant greater distance to the radial nerve compared to straight plates. However, distances remain low, and attention must be paid to the musculocutaneous nerve and the brachial artery when MIPO is used with ALPS, 45°- and 90°-helical implants. Anterior parts of the deltoid insertion will be detached using 90°-helical and ALPS implants in MIPO-technique

This single-centre prospective randomised trial aimed to assess the superiority of operative fixation compared with non-operative management for adults with an isolated, closed humeral shaft fracture. 70 patients were randomly allocated to either open reduction and internal fixation (51%, n=36/70) or functional bracing (49%, n=34/70). 7 patients did not receive their assigned treatment (operative n=5/32, non-operative n=2/32); results were analysed based upon intention-to-treat. The primary outcome measure was the DASH score at 3 months. Secondary outcomes included treatment complications, union/nonunion, shoulder/elbow range of motion, pain and health-related quality of life (HRQoL). At 3 months, 66 patients (94%) were available for follow-up; the mean DASH favoured surgery (operative 24.5, non-operative 39.4; p=0.006) and the difference (14.9 points) exceeded the MCID. Surgery was also associated with a superior DASH at 6wks (operative 38.4, non-operative 53.1; p=0.005) but not at 6 months or 1yr. Brace-related dermatitis affected 7 patients (operative 3%, non-operative 18%; OR 7.8, p=0.049) but there were no differences in other complications. 8 patients (11%) developed a nonunion (operative 6%, non-operative 18%; OR 3.8, p=0.140). Surgery was associated with superior early shoulder/elbow range of motion, and pain, EuroQol and SF-12 Mental Component Summary scores. There were no other differences in outcomes between groups. Surgery confers early advantages over bracing, in terms of upper limb function, shoulder/elbow range of motion, pain and HRQoL. However, these benefits should be considered in the context of potential operative risks and the absence of any difference in patient-reported outcomes at 1yr

The purpose of this study is to describe the use of the PHILOS plate (Synthes) in reverse configuration to treat complex distal humeral non-unions. Non-union is a frequent complication of distal humeral fracture. It is a challenging problem due to the complex anatomy of the distal humerus, small distal fragment heavily loaded by the forearm acting as a long lever arm with powerful forces increasing the chances of displacement. Rigid fixation and stability with a device of high “pull-out” strength is required. The PHILOS plate has been used in reverse configuration to achieve good fixation while allowing central posterior placement of the implant. 11 patients with established non-union of distal humeral fractures were included in this study. No patient in whom this implant was used has been excluded. Initial fixation was revised using the PHILOS plate in reverse configuration and good fixation was achieved. Bone graft substitutes were used in all cases. Patients were followed to bony union, and functional recovery. All fractures united. One required revision of plate due to fatigue failure. Average time to union was 8 months with excellent restoration of elbow function. A reversed PHILOS plate provides an excellent method of fixation in distal humeral non-union, often complicated by distorted anatomy and previous surgical intervention. It has a high “pull-out” strength and may be placed in the centre of the posterior humerus, allowing proximal extension of the fixation as far as is required. It provides secure distal fixation without impinging on the olecranon fossa. It is more versatile and easier to use than available pre contoured plating systems

The primary aim was to assess patient-reported outcomes following a humeral diaphyseal fracture. The secondary aim was to compare the outcomes of patients who achieved union after initial management (operative or non-operative) with those that achieved union after nonunion surgery. From 2008–2017, 291 patients (mean age 55yrs [17–86], 58% [n=168/291] female) were retrospectively identified and available to complete a survey. Sixty-four (22%) were managed with primary surgery and 227 (78%) non-operatively. Outcomes (QuickDASH, EQ-5D, EQ-VAS, SF-12) were obtained at a mean of 5.5yrs (1.2–11.0). After initial management, 229 patients (79%) united (n=62 operative, n=167 non-operative) and 62 (21%) developed a nonunion (n=2 operative, n=60 non-operative; p<0.001). Fifty-two of 56 patients (93%) achieved union after nonunion surgery. The overall mean QuickDASH was 20.8, EQ-5D 0.730, EQ-VAS 74, SF-12 PCS 44.8 and MCS 50.2. Patients who united after nonunion surgery reported a worse functional outcome (mean QuickDASH 27.9 vs. 17.6, p=0.003) and health-related quality of life (HRQoL; mean EQ-5D 0.639 vs. 0.766, p=0.008; EQ-VAS 66 vs. 76, p=0.036; SF-12 PCS 41.8 vs. 46.1, p=0.036) than those who united primarily. When adjusting for confounders, union after nonunion surgery was independently associated with poorer function (difference in QuickDASH 8.1, p=0.019) and HRQoL (difference in EQ-5D -0.102, p=0.028). Humeral diaphyseal union after nonunion surgery was associated with poorer function and HRQoL compared to patients who united primarily. Targeting early operative intervention to patients at risk of nonunion may have an important role, given the potential impact of nonunion on longer-term outcome

The treatment for Humeral Supracondylar fractures in children is percutaneous fixation with Kirschner wires using a unilateral or crossed wire configuration. Capitellar entry point with divergent wires is thought crucial in the lateral entry approach. Crossed wire configuration carries a risk of Ulnar nerve injury. Our department had recorded a number of failures and this required review. A search was conducted for children with this injury and surgical fixation. A two year time frame was allocated to allow for adequate numbers. The hospitals radiography viewing system and patient notes were utilized to gather required information. 30 patients from 2–14 years all underwent surgery on the day of admission or the following day. 18 had sustained Gartland grade 3 or 4 injuries. Unilateral configuration was used in 10 cases; a loss of reduction was noted in 5 of these with one case requiring reoperation. Crossed wires were used in 20 cases with a loss of reduction in 1. Crossed wire configuration provides a more reliable fixation with a lower chance or re-operation. Our DGH policy now advises the use of this configuration. A small “mini-open” ulnar approach is utilized with visualization and protection of the nerve

Acute fractures of the humeral shaft are usually managed conservatively. The rate of union is high, whereas that of nonunion ranges from 1 – 6%. Various risk factors for nonunion have been identified, including the following: open fracture, mid shaft fracture, transverse or short-oblique fracture, comminuted fracture, unstable fixation, fracture gap. This paper evaluates the results of treatment of humeral shaft fracture by open reduction and internal fixation with DCP, supplemented with cancelous bone graft but not in all cases. One hundred and five cases of nonunion of a humeral shaft fracture between 1988 and 2006 were analyzed retrospectively. The study population comprised 66 males and 39 females with an average of 46.2 years (range, 17 – 81 years). Sixty seven fractures were defined as atrophic nonunion, and 20 as hypertrophic nonunion, whereas 18 could not be defined clearly. All the fractures were managed by open reduction and internal fixaztion with DCP and cancelous bone graft. The mean follow up period was 20 months (range, 14 – 28 months). All nonunion fractures united within an average of 16 weeks (range 10–26 weeks). Complications included 4 patients with temporary radial nerve palsies, and 3 patients with wound infections. At the final follow-up shoulder and elbow functions of the operated limbs were all satisfactory. Fixation by DCP with supplemental cancellous bone graft is a reliable and effective treatment for nonunion of a humeral shaft fracture

Background. Although minimally invasive plate osteosynthesis (MIPO) has become popular option for humeral shaft fractures, indirect reduction and its maintenance are technically challenging. The purpose of this study is to describe a reproducible technique utilizing an external fixator during MIPO and to assess its outcomes. Methods. Twenty-nine cases with a mean age of 37.1 years were included. There were 7 simple (type A) and 22 comminuted (type B or C) fractures. Indirect reduction was achieved and maintained by a monolateral external fixator on the lateral aspect of humeral shaft, and MIPO was performed on the anterior surface. Union, alignment, complications, and functional results of the shoulder and elbow were assessed. Results. Twenty-eight of 29 fractures were united with a mean of 19.1 weeks including 3 delayed unions. The mean follow-up period was 20.8 months. There was one hypertrophic nonunion, which was healed after fixing two additional screws. None had angulation greater than 10 degrees in the coronal and sagittal planes. Mean constant shoulder score and mean Mayo elbow performance score were 89.1 and 95.5, respectively. There was no direct damage to nerves related to the pin of external fixator, while two cases of radial neuropraxia developed, which recovered within 2 months after operation. Conclusion. Assisted by the preliminary external fixation, MIPO may achieve successful outcomes for humeral shaft fractures

Objectives: To evaluate and compare the results of interlocking nailing (ILN) and plating (PL) in fresh humeral shaft fractures (HSF). Material and Methods: During 7 years period 145 patients with HSF (84 males and 61 females) were operated and followed up for 8 – 60 months (mean 18 months). According to AO there were 64 Type A, 53 Type B and 28 Type C fractures. Of 18 open injuries there were 10 grades I, 5 grades II and 3 grades IIIA. There were 33 patients with polytrauma, 11 cases with associated limb injuries, 9 cases with floating elbow and 22 patients with primary neurological deficit. In 75 fractures ILN was performed and PL in rest 70. Results: The mean operative time was 85 min for ILN vs./117 min for PL and the mean blood loss 100ml vs./250 ml. Healing occurred in 139(95.6%) fractures with mean healing time 75 days vs./85 days. Functional results according to Rommens score were as follows. Shoulder: excellent 62(82.6%) vs./55(78.5%), good 11(14.6%) vs./11(15.7%), poor 2(2.8%) vs./4(5.8%). Elbow: excellent 69(92%) vs./52(74.3%), good 6(8%) vs./16(22.8%), poor 0 vs./2(2.9%). Complications noted were iatrogenic nerve palsy 1(1.3%) vs./12(17%), delayed union 5(7%) vs./2(3%), non union 1(1.3%) vs./5(7%), infection 0 vs./1(1.4%), fixation failure 1(1.3%) vs./5(7%) and reosteosynthesis 1(1.3%) vs./1(1.4%), shoulder impingement 8(11%) vs./2(3%). Conclusions: Interlockimg nailing reduces risk of nerve injury and infection, provides more stability in segmental, complex and osteoporotic HSF. No significant differences in the term of healing in the both methods. Plating should be preferred in open Fx with incidental nerve palsy or vascular injury and juxtaarticular Fx, especially distally located. The method provides anatomical reduction, but requires extended approach and increases risk of iatrogenic nerve palsy